[assessment]
[assessment]
The patient was with her husband, who might be the primary caregiver, at the time of my visit approximately 08:45 on 2023-01-13. I gave the patient the Kisqali (ribociclib) empty package along with the insert inside.
It has been explained to the patient that they should be alert for any signs of adverse reactions of the drug such as interstitial lung disease, pneumonitis, cutaneous adverse reactions, prolonged QT intervals, hepatobiliary toxicity, and neutropenia; and to comply with the doctor’s instructions and cooperate with the regular lab tests.
A small amount of redness and itching can be seen on the back of the patient’s neck, and there appears to be a small break in the mouth near the lips. Please follow up.
In MONALEESA-7, the observed mean QTcF increase from baseline was > 10 ms higher in the tamoxifen plus placebo subgroup compared with the non-steroidal aromatase inhibitors (NSAIs) plus placebo subgroup. In the placebo arm, an increase of > 60 ms from baseline occurred in 6/90 (7%) of patients receiving tamoxifen, and in no patients receiving an NSAI. An increase of > 60 ms from baseline in the QTcF interval was observed in 14/87 (16%) of patients in the KISQALI and tamoxifen combination and in 18/245 (7%) of patients receiving KISQALI plus an NSAI.
Following coadministration of ribociclib with anastrozole, letrozole, exemestane, and fulvastrant, clinical trial data indicate that there are no clinically relevant drug interactions between ribociclib and these drugs.
Palbociclib and abemaciclib are two other kinase inhibitors that are compatible with aromatase inhibitors and both are available in the stock.
Please monitor ECG and electrolytes very closely if the combination of ribociclib and tamoxifen cannot be avoided.
[assessment]
There was neutropenia of grade 2 (2023-01-13 1.02K/uL) as well as suspected tumolysis syndrome (2023-01-11 P 7.3mg/dL, Ca 2.0mmol/L, uric acid 8.3mg/dL) in this patient. please consider whether G-CSF is necessary in the next few days.
Rolikan (sodium bicarbonate) has been prescribed since 2023-01-13. The role of urinary alkalinization with either acetazolamide and/or sodium bicarbonate is unclear and controversial. In the past, alkalinization to a urine pH of 6.5 to 7 or even higher was recommended to increase uric acid solubility, thereby diminishing the likelihood of uric acid precipitation in the tubules. However, this approach has fallen out of favor for the following reasons: 1. There are no data demonstrating the efficacy of this approach. In addition, the only available experimental study suggested that hydration with saline alone is as effective as alkalinization in minimizing uric acid precipitation.; 2. Alkalinization of the urine has the potential disadvantage of promoting calcium phosphate deposition in the kidney, heart, and other organs in patients who develop marked hyperphosphatemia once tumor breakdown begins. (ref: https://www.uptodate.com/contents/tumor-lysis-syndrome-prevention-and-treatment).
Febuxostat is administered to this patient currently. The level of uric acid has decreased to 3.8 mg/dL as of 2023-01-13.
{not completed}
[assessment]
2022-12-13 lab results
The reactive antibodies above indicated the patient had been infected with the hepatitis B and C virus at some point in time. Infection with HBV and/or HCV is a common disorder that can be exacerbated or reactivated with cytotoxic chemotherapy.
Baraclude (entecavir) has been prescribed for HBV management. Patients with chronic HCV infection who are receiving chemotherapy should undergo serial monitoring of LFTs, since the recent AST/ALT in this patient were normal and with no dramatic change, continued chemotherapy treatment without dose modification is appropriate.
Despite taking Relinide (repaglinide) and Galvus (vidagliptin and metformin), the patient’s blood sugar is not well controlled (2023-01-12 210mg/dL, 2023-01-13 172mg/dL). Hyperglycemia might be mitigated with addition of SGLT2 inhibitors, e.g., canagliflozin, dapagliflozin, empagliflozin.
[tube feeding]
Current administration routes are IVD and TPN; there is no tube feeding at this time.
{Management of vasogenic edema in patients with primary and metastatic brain tumors - glucocorticoids} - ref: https://www.uptodate.com/contents/management-of-vasogenic-edema-in-patients-with-primary-and-metastatic-brain-tumors
2023-01-11 brain MRI showed increased heterogeneous soft tissue enhacement in the right temporal lobe and right cavernous sinus with right cavernous ICA encasement. suspected radiation necrosis or tumors.
Systemic glucocorticoids are the mainstay of symptomatic therapy for peritumoral edema. They play a role in stabilizing patients awaiting definitive treatment of the tumor as well as in palliative management of edema related to treatment-refractory tumors.
Emergency management of increased ICP
Initiation of glucocorticoids
Dexamethasone dose and schedule
Response assessment
Inadequate response to initial dose
Approach to taper
Refractory edema
Symptomatic plateau waves
[assessment]
[assessment]
[assessment]
There is no specific pharmacist shift handover to follow in this patient.
[drug identification]
{SCC of esophagus, lower third, with mediastinal & SCF LAPs and multiple brain metastases, stage IV}
[assessment]
[tube feeding]
[note]
[assessment]
After over 15 kg of weight loss between late August and early December in 2022, the patient’s weight has remained at approximately 41kg for one month, with no further noticeable decline in her weight.
The elevated D-dimer readings are getting closer to the normal limits in a gradual manner. Given that the half-life of the D-dimer is only 15.8 (13.1 - 23.1) hours (ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2693750/), could this slow decline be indicative of latent fibrin degradation?
It is advised to assess LVEF immediately prior to pertuzumab/trastuzumab initiation, every 3 months during pertuzumab/trastuzumab therapy, every 3 weeks if pertuzumab/trastuzumab is withheld for significant left ventricular cardiac dysfunction, and every 6 months for at least 2 years following completion of adjuvant pertuzumab/trastuzumab therapy. Pre-pertuzumab/trastuzumab 2D transthoracic echocardiography was performed on 2022-08-11, so it might be in need of updating. (Nov and Dec 2022 CXR showed borderline cardiomegaly and enlargement of cardiac silhouette.)
Since bilirubin total was 0.95 mg/dL on 2023-01-11, there is no need to adjust the dose of paclitaxel.
[assessment]
Over 15 kg of body weight have been lost in the past four months (41.2kg 2022-12-15 <- 55.8kg 2022-08-24). It is possible that the serum creatinine level remains below LLN since August 2022 as a result of insufficient dietary intake or muscle mass loss (malnutrition, muscle wasting). It should be necessary to encourage the patient to consume more food and there may be benefits to prescirbe megestrol as an appetite stimulant.
The presence of elevated plasma D-dimer concentrations indicates recent or ongoing intravascular coagulation and fibrinolysis. Although the reading remained high, it trended downward, a relatively positive sign. The metastatic liver lesion reduced clearance of fibrin degradation products?
According to the patient’s updated liver function lab results, paclitaxel dosage does not need to be adjusted.
[assessment]
There is no specific pharmacist shift handover to follow in this patient.
[Zavicefta 2g/0.5g powder for concentrate for solution for infusion - Usage and Precautions ] for the patient’s primary nurse
[assessment]
[assessment]
[drug interaction]
The ability of oral iron preparations to reduce the absorption of oral quinolones is well established and has been demonstrated in numerous pharmacokinetic studies. Various oral iron preparations have been reported to reduce quinolone AUCs by the following percentages: ciprofloxacin (33% to 70%), levofloxacin (19%), lomefloxacin (14%), moxifloxacin (61%), norfloxacin (51% to 73%), ofloxacin (25%), and sparfloxacin (28%). The maximum serum concentrations of oral quinolones were reduced by the following percentages: ciprofloxacin (46% to 75%), levofloxacin (45%), lomefloxacin (28%), moxifloxacin (41%), norfloxacin (75% to 82%), ofloxacin (36%), and sparfloxacin (46%). It is recommended to administer oral quinolones at least several hours before (4 h for moxifloxacin and sparfloxacin, 2 h for others) or after (8 h for moxifloxacin, 6 h for ciprofloxacin and delafloxacin, 4 h for lomefloxacin, 3 h for gemifloxacin, 2 h for enoxacin, levofloxacin, norfloxacin, ofloxacin, pefloxacin, or nalidixic acid) oral iron preparations.
Due to the fact that Cravit (levofloxacin) and Foliromin (ferrous sodium citrate) were prescribed as QDAC and BID, respectively. To maintain Cravit’s effectiveness, Foliromin might be moved to QL and QN.
Please monitor for diminished effects of the quinolone if dose separation cannot be achieved.
Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected and urinary bladder fidtula, cT4bN2bM1c, stage IV
chief complaint
present illness
past history
lab data
exam finding
consultation
surgical operation
chemoimmunotherapy
[assessment]
Oxaliplatin is associated with high incidence of peripheral neuropathy (76%, grades 3/4: 7%; acute: 65%, grades 3/4: 5%; delayed (persistent): 43%, grades 3/4: 3%) Ref: UpToDate
The acute neurotoxicity that is seen frequently in the 72 to 96 hours after each infusion of oxaliplatin is often linked to cold exposure (drinking cold liquids, inhaling cold air, placing hands in the freezer). Avoidance of cold during this time frame should mitigate this toxicity to some extent, but not all symptoms (eg, perioral numbness, hand cramping) are related to cold. As of now, no evidence of peripheral neuropathy has been recorded.
The patient vomited several times throughout the week as documented in the record of 2023-01-06. A prescription for metoclopramide has been issued.
[assessment]
[assessment]
[assessment]
[assessment]
{not completed}
[assessment]
[duplicate note]
[assessment]
{Malignant neoplasm of body of stomach; gastric antrum, pT4aN0M1, stage IV status post radical subtotal gastrectomy with lymph node dissection and B-II gastrojejunostomy}
[assessment]
There has been a frequent low level of magnesium in the patient’s blood for months, this hospital currently has only magnesium oxide tablets available for oral administration, so it is recommended to continue prescribing MgO when he is discharged.
MgO should be taken with food and at least 240mL of water (absorption: oral up to 30%). Patients might be educated that whole grains, legumes, and dark-green leafy vegetables are dietary sources of magnesium.
[assessment]
As multiple body fluid (primarily ascites) cytological studies (2022-11-18, -11-17, -10-27, -10-26, -10-04, -09-14, -09-13, -09-01, -08-30) did not reveal evidence of malignancy, intraperitoneal chemotherapy was discontinued while systemic FOLFOX is continued.
The lab serum magnesium levels indicated a frequent deficiency of serum magnesium in this patient.
For the magnesium sulfate prescription will expire on the weekend, a lab data renewal may assist in determining whether the magnesium supplement should continue to be administered.
[assessment]
Body weight has decreased by almost 10 kg in the last 3 months (33.1kg 2022-10-25 <- 42.8kg 2022-07-27 gastrectomized), and a low albumin level (3.2 g/dL 2022-10-25) could indicate malnutrition. Long-term survival may be adversely affected by malnutrition after gastrectomy for gastric cancer (ref: Impact of Malnutrition After Gastrectomy for Gastric Cancer on Long-Term Survival. Ann Surg Oncol. 2018;25(4):974-983. doi:10.1245/s10434-018-6342-8)
It is advisable to begin strict nutritional follow-up as soon as possible after surgery in order to prevent a sharp weight loss in the early postoperative phase when most of the dietary problems arise.
Vitamin B12 injections might be required, as well as multivitamins and minerals.
As this patient’s weight is approximately equivalent to that of a ten-year-old child, the dosage might need to be adjusted accordingly.
[drug interaction]
[assessment]
As of 2023-01-10, WBC is 2.87K/uL, neutrophil is 53%, and ANC is greater than 1500 cells/uL.
However, there is a trend downward in WBC count which should be noted.
[assessment]
[assessment]
[assessment]
[assessment]
{Recurrent left breast cancer with bilateral lung, right pleura, liver, bone and lymph node metastases, rcTxN2M1, stage IV}
[note]
[assessment]
[assessment]
Despite the use of Radi-K (potassium gluconate, since 2022-10-04) in conjunction with spironolactone (since 2022-10-10), lab data on 2022-10-13 show serum potassium at 2.7mmol/L still below normal (3.5~5.1). It is recommended to shift oral Radi-K from TID to QID or add a potassium supplement injection to prevent low K from becoming symptomatic.
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
Methotrexate induced acute renal failure is typically nonoliguric and is reversible in almost all cases. Plasma creatinine levels usually peak within the first week and return toward baseline levels within 1 to 3 weeks. The patient’s renal function is decreasing at a much slower rate over time, which is a positive sign that creatinine almost reaches its peak level.
The likelihood of MTX-induced renal dysfunction in patients receiving high dose MTX can be minimized (but not eliminated) by hydration both to maintain a high urine flow and to lower the concentration of MTX in the tubular fluid and by alkalinization of the urine to a pH above 7.0. Raising the urine pH from 5.0 to 7.0 increases the solubility of MTX 10-fold.
It is customary to begin the MTX infusion only after the urine pH is >= 7.0 and to maintain it in this range until plasma MTX levels have declined to less than 0.1 microM.
Urinary alkalinization is most easily accomplished by adding ampules of sodium bicarbonate to each liter of IV fluid hydration. This accomplishes both fluid hydration and urinary alkalinization. A typical choice is IV D5W with 100 to 150 mEq of sodium bicarbonate per liter, administered by continuous infusion at 125 to 150 mL/hour. A cation concentration of 80.5 mEq/L is roughly equivalent to one-half normal saline. The amount of bicarbonate in each liter and the IV fluid composition can then be modified according to the urine pH and serum sodium.
An alternative oral protocol for sodium bicarbonate can be started with 3000 mg (300mg/tab * 10 tablets) Q6H, and can be escalated the frequency to Q4H as needed; once the urine pH is greater than 7, the 24 hour daily dose can then be lowered and divided into four doses, every six hours.
[note]
methotrexate (https://www.uptodate.com/contents/methotrexate-drug-information 2022-07-20)
leucovorin (https://www.uptodate.com/contents/leucovorin-drug-information 2022-07-20)
[assessment]
Lab data indicated that the patient’s renal function is deterioating
In this male patient, who is 56 y/o, Cre 2.02 mg/dL and weighs 82 kg, the estimated CrCl is 47 mL/min. The self-carried Baraclude (entecavir) for patients with CrCl 30 to <50 mL/minute: Administer 50% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 48 hours. QODAC is preferred.
Methotrexate is greater 80% excreted as the unchanged drug and is primarily excreted in the urine. Leucovorin 100mg IVD Q6H has been administered since 2023-01-08 06:05.
Serum MTX levels are declining at an apparent rate.
If the patient is still able to urinate normally, furosemide may be an option for helping the excretion of methotrexate. For patients with an eGFR greater than 30 mL/minute/1.73m2, furosemide does not require dosage adjustment.
[assessment]
= 27 None
[assessment]
Neutropenia has be mitigated with filgrastim (G-CSF)
Over the past three months, the IgA levels have been around 500 +- 50 mg/dL, relatively stable, but showing a slowly upward trend.
Revlimid (lenalidomide) has demonstrated a significantly increased risk of deep vein thrombosis (DVT) and pulmonary embolism (PE), as well as risk of myocardial infarction and stroke in patients with multiple myeloma who were treated with lenalidomide and dexamethasone therapy. Please monitor for and advise patients about the signs and symptoms of thromboembolism as always.
Ninlaro (ixazomib) has been prescribed as a self-paid item and is not listed on PharmaCloud nor in the active prescriptions. Please make sure that the patient’s ANC be greater than 1000/mm3, platelets be greater than 75,000/mm3, and nonhematologic toxicities be at baseline or less than grade 1 (per prescriber discretion) prior to initiating a new cycle of therapy. It is recommended that patients who are seropositive for Varicella zoster virus (VZV) and herpes simplex virus (HSV) receive an antiviral prophylaxis with acyclovir or valacyclovir prior to receiving a proteasome inhibitor (bortezomib, carfilzomib, ixazomib), as there is an increased risk of reactivation if the proteasome inhibitor is used.
[tube feeding]
Broen-C (bromelain + L-cysteine) is an enteric-coated tablet designed to prevent the destruction of the bromelain enzyme by gastric juice.
Bromelain is sensitive to extreme conditions such as high temperature, gastric proteases in stomach juice, high acidity, and organic solvents, and thus, reduces its functionalities and bioavailability. Its instability under such stress conditions reduce its enzymatic activity, decrease its health benefits, and limit its pharmacological applications. ref: Mala T, Anal AK. Protection and Controlled Gastrointestinal Release of Bromelain by Encapsulating in Pectin-Resistant Starch Based Hydrogel Beads. Front Bioeng Biotechnol. 2021;9:757176. Published 2021 Oct 29. doi:10.3389/fbioe.2021.757176
There are no other drugs in the inventory that contain bromelain.
{Squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence. Squamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0.}
[note]
[assessment]
[tube feeding]
Except for Broen-C, all oral medications in the active prescription can be administered by nasogastric tube.
In order to prevent the bromelain enzyme from being destroyed by gastric juice, Broen-C (bromelain + L-cysteine) is designed as an enteric-coated tablet.
[assessment]
{tube feeding}
With the exception of Boren-C, all other drugs in the active prescription can be administered via nasogastric tube.
As an enteric-coated tablet, Boren-C is designed to prevent gastric acids from destroying its key ingredient, bromelain enzyme.
[assessment]
[assessment]
[assessment]
[assessment]
{colon cancer with lung and liver metastases, T4aN2bM1b, stage IVB}
[assessment]
[tube feeding]
[assessment]
[assessment]
[assessment]
{colon cancer with lung and liver metastases, T4aN2bM1b, stage IVB}
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[tube feeding]
The oral medications in the active prescription can all be administered by tube feeding.
[assessment]
[assessment]
{High grade B-cell lymphoma with left aspect of mandible, multiple lymph nodes in the abdomen and the regions about the pericardium and pleura of left lower lung field, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1}
[assessment]
Cimetidine may increase the serum concentration of metformin. The AUC of metformin increased 40% when combined with a single dose of cimetidine (400 mg) and increased 50% after treatment with cimetidine (400 mg twice daily) for 5 days in healthy volunteers. In an another study of 15 healthy volunteers, cimetidine administration decreased metformin renal tubular clearance by 18.7% to 48.2%, depending on the individual’s organic cation transporter 2 (OCT2) genotype. Participants carrying the OCT2 808G>T polymorphism had lower baseline tubular clearance of metformin and a correspondingly lower magnitude of interaction with cimetidine.
As the patient’s renal function still works (2023-01-05 Cre 1.08mg/dL, eGFR 53, BUN 14mg/dL), it is less likely to develop lactic acidosis, however, close monitoring might be necessary.
The historical time series lab data suggest that the roughly cyclic trough WBC level (neutropenia events) was frequently observed around 3 weeks following each R-CHOP treatment. It might be necessary to plan in advance for the possible neutropenia 3 weeks after this hospital stay in order to ensure the G-CSF is accessible to the patient during the Chinese New Year long holidays.
[assessment]
[assessment]
[assessment]
[assessment]
[objective]
[assessment]
[assessment]
[OxyNorm tube feeding]
[no sodium version of piperacillin + tazobactam]
{tube feeding}
It is possible to peel the Concor (bisoprolol 1.25mg) tablet in half or grind it for tube feeding.
[assessment]
High bilirubin (total and direct), AST, ALT; slightly high Glucose (AC), HbA1c; slightly low serum Na, K have been seen in lab data on 2022-12-28/29.
There is no past history of hypercholesterolemia or available laboratory data to support this condition, Tulip (atorvastatin) might not be indicated.
{Prostate cancer, pT3bN1cM0, s/p RARP on 2015-06-30, s/p adjuvant radiotherapy on 2015-09-25 and hormone therapy with refractory, progression of metastatic paraaortic lymph nodes and bone metastases, T0N0M1a, stage IV}
[assessment]
2023-01-04 lab data were generally normal, except for a slight decrease in WBC and HGB levels. The vital signs of the patient are stable during this hospitalization.
All underlying conditions, including HBV, hypothyroidism, and insomnia, are managed with appropriate medication.
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[suggestion]
[assessment]
[suggestion]
[assessment]
A higher overshoot of bilirubin total than bilirubin direct might hint a sign that the patient’s red blood cells are breaking down at an unusual high rate.
During the first half hour of 14 o’clock 2023-01-04, there was a brief tachycardia moment with SBP exceeding 200mmHg. The vital signs are relatively stable now.
According to the Concor (bisoprolol 5mg/tab) package insert, the drug shold be swallowed with some liquid and not to be chewed. We are in the process of consulting the distributor for a response.
Atenolol can be used as an alternative antihypertensive agent (atenolol 50mg ~ bisoprolol 5mg) available under the brand name Urosin in the stock.
[assessment]
Based on the available lab data, serum Ca levels are stably lower than the normal range. If PTH secretion is insufficient to act on kidney, bone, and intestines, hypocalcemia may occur (hypoparathyroidism). No PTH lab data available. As the serum albumin concentration is also below normal, the low calcium level could also be due to a reduction in serum albumin levels.
Even when potassium supplements are taken intermittently, serum K readings remain below normal range since December 2022. An acute increase in hematopoietic cell production is associated with potassium uptake by the new cells and this may lead to hypokalemia. Administration of vitamin B12 or folic acid to treat a megaloblastic anemia or use of granulocyte-macrophage colony-stimulating factor (GM-CSF) to treat neutropenia are the most common scenarios in which this occurs.
[assessment]
[assessment]
[assessment]
diphenhydramine 30mg + granisetron 1mg diphenhydramine 30mg diphenhydramine 30mg + granisetron 1mg[assessment]
{triple negative breast cancer}
[note]
[assessment]
{triple negative breast cancer}
[note]
[assessment]
{triple negative breast cancer}
[note]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
The lab data indicated that MCV, MCH, MCHC, UIBC were normal; Ferritin was exceeded; Fe (iron bound) and TIBC was low.
Normal MCV, MCH, MCHC may suggest the anemia is less likely to be caused by iron insufficiency. High ferritin may suggest iron overload. Low TIBC can suggest that there is not enough transferrin available to bind to iron, i.e., the patient has high iron level, so most of the transferrin is bound to it, which leaves very little free in his blood. Frequent blood transfusions may cause iron overload.
It is recommended to hold the Foliromin (ferrous sodium citrate) until the cause of the anemia is confirmed to be iron deficiency.
[assessment]
[assessment]
[assessment]
{Trimethoprim/Sulfamethoxazole (TMP/SMX) dosing}
Trimethoprim/sulfamethoxazole(TMP/SMX) for patients with moderate to severe Pneumocystis pneumonia infection: IV 15 to 20 mg/kg/day (TMP component) in 3 or 4 divided doses; may switch to oral therapy after clinical improvement.
As recent lab results revealed no abnormalities in the liver and kidney functions, it is less likely that dosage adjustments will be needed.
Patients with moderate or severe infection (PaO2 <70 mm Hg at room air or alveolar-arterial oxygen gradient >= 35 mm Hg) should receive adjunctive glucocorticoids.
[assessment]
[assessment]
[assessment]
{Sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC}
[assessment]
[assessment]
[assessment]
After image studies in early Oct 2022 revealed a number of lesions with a mild increase in size, and multiple bone metastases in progress, the regimen was changed from FOLFIRI to FOLFOX.
In the past three months, certain tumor markers have been elevated.
As SBP highly fluctuated between 136 and 231 under treatment with (patient-carried medication) Concor (bisoprolol), Zanidip (lercanidipine) and Hyzaar (losartan + hydrochlorothiazide), please monitor this closely. The drug Atanaal (nifedipine 5mg) 1# PRNQ6H might be considered in case where the blood pressure exceeds 200mmHg.
SBP flucturated at a wide range 136~231mmHg under patient-carried antihypertensive agents Concor (bisoprolol) and Hyzaar (losartan + hydrochlorothiazide), please keep a closer eye on it.
Pre-prandial blood sugar levels were higher than 170mg/dL for 2 days; metformin 500mg BID is recommended.
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
{colon cancer}
[initial presentation]
[definite diagnosis]
[disease extent]
[treatment/plan]
[effect and side effect]
[ongoing problem]
<diabetes mellitus, type 2>
[note]
[assessment]
[assessment]
It appears that the approximate cycled trough WBC count occured around one week after the administration of single bleomycin agent, the G-CSF administration might follow this pattern.
The AFP/beta-HCG/LDH tests might be conducted again in December 2022 to make the monitor frequency not fall below two months. (There were still superior mediastinal widening and an enlarged Lt hilum on the CXR of 2022-11-30)
Pulmonary fibrosis is the most severe toxicity associated with bleomycin. The most frequent presentation is pneumonitis occasionally progressing to pulmonary fibrosis. Its occurrence is higher in elderly patients and in those receiving more than 400mg total dose, but pulmonary toxicity has been observed in young patients and those treated with low doses.
[assessment]
Lab data from selected tumor markers revealed that each marker had a different trend without an overall trend.
The WBC is boosted with lenograstim when neutropenia is observed following the BEP regimen.
Chronic hepatitis B is treated appropriately with Baraclude (entecavir) 0.5mg QDAC.
The active prescription is not subject to any issues.
[assessment]
The primary chemotherapy regimen for germ cell tumors could be BEP, which consists of the following components (NCCN).
AST, ALT, Cre, and eGFR (2022-10-19) did not exhibit abnormalities, therefore no dose adjustment would be required for the BEP regimen based on pharmacokinetics.
The dose used is slightly lower than that recommended by the NCCN (currently: 80mg/m2 of etoposide, 15mg/m2 of cisplatin. NCCN: 100mg/m2, 20mg/m2). Given that the patient’s performance status scale is ECOG 0, it might be an option to upgrade the dose to meet the guideline to obtain more expected effects if no other considerations exist.
[assessment]
[assessment]
[assessment]
[assessment]
{esophageal SCC moderately differentiated T3N2M1 with lung mets}
[objective]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
{drug identification}
The drug imprinted “CTP A23” on the red-white capsule has not been found in available databases and remains unidentified.
{ABX use evaluation}
For most adults, the initial recommended antifungal treatment is an echinocandin (caspofungin, micafungin, or anidulafungin) given through the vein. Fluconazole, amphotericin B, and other antifungal medications may also be appropriate in certain situations.
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
{drug identification}
requesting drug identification for 2 items.
all the 2 items are identified as following…
these drugs will be sent back to ward by an in-hospital porter.
[note]
[assessment]
During the past month, the patient’s liver and kidney functions have declined.
As the patient’s CrCl level is 17 mL/min according to the Cockcroft-Gault formula, it is recommended that the dosage of clarithromycin and amoxicillin be halved.
For patients with severely impaired kidney function, neither cisplatin nor carboplatin is recommended. Cetuximab is being administered as part of the patient’s treatment with CCRT.
In this patient, transthoracic echocardiography (2022-11-22) revealed dilated atria and RV, grade 1 LV diastolic dysfunction, mild AR, MR, and PR, moderate to severe TR, and pulmonary hypertension. Cardiopulmonary arrest or sudden death occurred in patients with squamous cell carcinoma of the head and neck receiving cetuximab with radiation therapy or a cetuximab product with platinum-based therapy and fluorouracil. It is recommended to closely monitor serum electrolytes, including magnesium, potassium, and calcium, during and after cetuximab administration.
{not completed}
{not completed}
[assessment]
[assessment]
[assessment]
{drug identification}
A request has been made for us to identify drugs for 10 items.
In total, 9 items have been identified as follows, with 1 item remaining unidentified.
These drugs will be sent back to ward by the in-hospital porter.
[assessment]
{Diffuse large B-cell lymphoma, stage IV, with bilateral lung and adrenal gland metastasis. triple hit, IPI:4}
{not completed}
[assessment]
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[assessment]
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All-RAS + BRAF + IHC results were like 700811991’s.
[assessment]
{Left breast cancer, pT2N1aM0, ER(+), PR(+), Her2(-), stage IIA s/p MRM on 2022-05-13}
[note]
[assessment]
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[assessment]
[assessment]
{Metastatic colon adenocarcinoma in liver S4-5-8 & S6, pTxN0M1a Stage IVA, post segmental hepatectomy on 2019-06-05}
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[cyclosporine trough concentration]
As a follow-up of the change in dose of cyclosporine from 100mg Q12H to 120mg Q12H since 2022-11-25, it is recommended that the trough concentration of cyclosporine be renewed by drawing blood within 30 minutes of the first dose on 2022-11-29.
[cyclosporine trough concentration]
Following the administration of 100 mg Q12H since 2022-11-21, a blood sample was taken for cyclosporine trough concentration, and the level was 63.9 ng/mL. In general, the effective range is considered to be between 100 and 400 ng/mL. In the event that the clinical effect not shown, increasing the daily dose to 300mg (divided in 3 seperate administration) can be considered and then recheck the trough concentration 3 days after the dose alteration. The goal is to limit the concentration with a minimum dose while retaining the necessary clinical effect.
According to UpToDate database, cyclosporine for patients with altered kidney function, CrCl <60 mL/minute: No dosage adjustment necessary (0.1% excreted in the urine unchanged) (Nemecek 2019; expert opinion). For nontransplant indications (eg, autoimmune disease), the manufacturer’s labeling states use is contraindicated in patients with abnormal renal function (not defined); however, when potential benefits outweigh the risks, may consider cautious use with frequent monitoring of kidney function, or consider use of an alternative agent due to increased risk of worsening kidney function, especially for patients with more severe impairment (expert opinion).
{Chronic myelomonocytic leukemia, CMMoL}
{Chronic myelomonocytic leukemia, CMMoL}
[assessment]
[assessment]
[assessment]
[assessment]
{NSCLC, not completed}
[note]
this patient EGFR L858R mutation detected, ROS1 (IHC 1+, FISH undetected)
NCCN v5.2022
[assessment]
[assessment]
[assessment]
lab data
exam findings
consultation
radiotherapy
chemoimmunotherapy
[assessment]
The disease is characterized by L858R(+), exon19del(-), ALK(-), and PD-L1<1%. This patient has been treated with oral afatinib(2021-12 ~ 2022-07)/dacomitinib(2022-08 ~ undergoing) and IV ramu(2021-12 ~)/nivo(2022-01 ~)/ipi(2022-03 ~). It appears that the current regimen is still effective to keep the disease stable (2022-02 and 2022-06 CT: regression; 2022-09 CT: stationary).
The serum potassium level in 2022-10-17 was 2.9 mmol/L, and it might be beneficial to add potassium supplements.
The main concern for the patient and his caregiver might be pain management. For patients who require four or more doses of short-acting opioids consistently each day, addition of a long-acting opioid should be considered based on the total daily dose. A controlled-release oxycondone regimen has been prescribed to the patient since 2022-10-18.
In the event that the patient’s goals are not met (uncontrolled pain persists), then administer an opioid dose equivalent to 10%~20% of the total opioid taken in the previous 24 hours and reassess effectiveness and adverse effects (at 15 minutes if administered IV or at 60 minutes if administered PO).
{gastric cancer, T1a pN3a (6/32) cM0, pStage: IIB, s/p Op on 20220414}
[assessment]
The serum ALT level trended upward.
The use of oxaliplatin has been associated with an increase in ALT levels (incidence of 36% with monotherapy)
There is no need to adjust the dosage of the components in the current regimen of FOLFOX.
The addition of pyridostigmine as a self-carried item is recommended for the patient with myasthenia gravis since this medication has no known heavy interactions with the active prescription.
[assessment]
{Left ovarian cancer (clear cell carcinoma) post Debulking surgery on 2022/06/08, pT2aN0M0, FIGO stage IIA}
[assessment]
Currently, Tecopin (teicoplanin 200mg/vial) is out of stock and has been replaced with Targocid (teicoplanin 200mg/vial). If the teicoplanin treatment should continue, please prescribe Targocid.
{Recurrent hepatocellular carcinoma with lung metastasis, rycT3N0M1, stage IVB}
[note]
[assessment]
[assessment]
A multicenter phase II trial (RENOBATE) demonstrated that regorafenib plus nivolumab as first-line therapy for unresectable hepatocellular carcinoma shows promising efficacy outcomes without unexpected safety signals. (ref: Regorafenib plus nivolumab as first-line therapy for unresectable hepatocellular carcinoma (uHCC): Multicenter phase 2 trial (RENOBATE). Changhoon Yoo, etc. Journal of Clinical Oncology 2022 40:4_suppl, 415-415. https://ascopubs.org/doi/abs/10.1200/JCO.2022.40.4_suppl.415 )
Since the end of 2021, Stivarga (regorafenib 40mg/tab) has been prescribed. It is administered at 160mg once daily (4# QD) for the first 21 days of a 28-day cycle. Hand-foot skin reaction has been observed.
[assessment]
2022-12-03 CXR
2022-11-21, -11-17 CXR
2022-11-18 SONO - chest
2022-11-13 ECG
2022-10-20 CT - abdomen
2022-10-14 CXR
2022-07-29 Whole body PET scan
2022-07-28 CT - chest
2022-06-06 Patho - lymphnode biopsy
2022-06-06 CT - abdomen
2022-05-31 2D transthoracic echocardiography
2022-05-23 Patho - lymphnode biopsy
2022-05-23 Patho - breast biopsy (no need margin)
2022-05-17 SONO - breast
2022-03-09 CT - abdomen
2021-12-09 Whole body PET scan
2021-11-26 CT - abdomen
2021-11-18 SONO - abdomen
2021-08-27 CT - abdomen
2021-07-08 Gynecologic ultrasonography
2021-06-10 CT - abdomen
2021-05-27 SONO - abdomen
2021-03-10 CT - abdomen
2020-12-01 Patho - soft tissue tumor, extensive resection
2020-11-30 Patho - ovary (tumor)
2020-11-18 Whole body PET scan
2020-11-18 Gynecologic ultrasonography
2020-11-16 CT - abdomen
2020-10-28, -09-16, -09-15, -08-26, -08-25, -08-13 Body fluid cytology - ascites
2020-08-13 Patho - peritoneum biopsy
2020-08-07 Patho - ovary biopsy/wedge resection
2020-08-06 Gynecologic ultrasonography
2020-08-05 CT - abdomen
2020-08-05 SONO - abdomen
2020-05-16 Mammography
consultation
chemoimmunotherapy
{Pseudomyxoma peritonei (mucinous carcinoma peritonei), grade 1}
[assessment]
[assessment]
[assessment]
{drug identification}
Total 1 drug for identification.
The identified item is Vemlidy film-coated tablet containing tenofovir alafenamide 25mg which is indicated for the treatment of chronic hepatitis B virus (HBV) infection in adults with compensated liver disease.
The drug will be sent back to ward by the in-hospital porter.
[assessment]
{serous carcinoma of right fallopian tube with peritoneal and pleural invastion with tumor recurrent, pT3cN1aM1a, stage IVA}
[objective]
[note]
[assessment]
[assessment]
{pancreatic cancer, endometrial cancer}
[assessment]
It should be noted that both serum creatinine and BUN increased 50% in the last two weeks (Cre 1.76 mg/dL 2022-11-30 <- 1.18 mg/dL 2022-11-16; BUN 33 mg/dL 2022-11-30 <- 20 mg/dL 2022-11-16), as well as bilirubin total exceeded 6 x ULN (6.95 mg/dL 2022-11-30).
2022-11-30 eGFR 31.2
2022-11-30 bilirubin total 6.95 mg/dL, ALT 442 U/L, AST 342 U/L
It is suggested to ensure that the patient’s kidney and liver function are in good condition prior to the chemotherapy.
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
In the last 3 weeks, the serum creatinine level has increased (1.24 2022-10-19 <- 1.18 2022-10-04 <- 0.80 2022-09-26). Please monitor the renal function if it continues to decline.
[assessment]
[assessment]
[note]
[assessment]
[assessment]
{This 80-year-old man patient is a case of Diffuse large B-cell lymphoma, Non-GCB type, at the right maxillary gingiva and tuberosity, Ki-67 index >95%, Lugano stage II, IPI score: 1, Low risk group, PS:0}
[assessment]
{Esophageal cancer, cT2N2Mo stage III, Port-A insertion at left cephalic vein on 20220922, jejunostomy tube insertion at abdomen on 20220922}
[assessment]
{drug interaction}
Morphine (8mg IVD PRNQ6H currently) is contraindicated when used concurrently with monoamine oxidase inhibitors (MAOIs, linezolid 600mg IVD Q12H currently).
There is a possibility that monoamine oxidase inhibitors may enhance the adverse/toxic effects of morphine. Please monitor any possible adverse reactions carefully.
{Protocol: Capsule suspension preparation and NG tube dispensing procedures for Xtandi (enzalutamide, 160mg dose)}
The following in-situ oral dosing syringe suspension preparation and NG tube dispensing procedures were identified as being facile and which essentially eliminate human exposure to capsule components:
Utensils: Tweezers, medical grade scissors, 2-3mL oral dosing syringe, 20mL oral dosing syringe, NG tube, and one 2-3 oz (60-90 mL) glass or plastic dosing container (e.g., beaker or med cup).
Materials: Ethanol, 95%, Deionized water, 4x40mg enzalutamide capsules
Please prepare two vials of 99.5% alcohol (drug code ‘CALCO01’), add one ml of purified water, take eight ml of the solution to dissolve one split capsule of 40 mg Xtandi, and tube feed this solution containing enzalutamide with prandial.
[assessment]
[assessment]
[assessment]
{Mesenchymal chondrosarcoma, high grade}
[assessment]
[assessment]
[assessment]
{metastatic breast cancer}
[assessment]
[assessment]
[assessment, suggestion]
[assessment]
[note]
[assessment]
The GOLF regimen was introduced as a neoadjuvant treatment since late August 2022 with the aim of downstaging the tumor. The CT (2022-11-16) revealed that the adenocarcinoma of the duodenal bulb showed a mild increase in size and that the metastatic nodes displayed a decrease in size. There appears to be a greater likelihood that this will improve the feasibility of the surgery.
The decreased CA199 marker also served as a side evidence that the regimen is still effective.
Data available indicate stable vital signs, and there is no problem with the active prescription.
[assessment]
{drug identification}
requesting drug identification for 4 items.
the 3 items are identified as following while the other 1 item remains unknown.
The drug will be sent back to ward by the in-hospital porter.
[assessment]
[assessment]
{drug identification}
It was requested that four drugs be identified.
The items identified are as follows:
These drugs will be sent back to ward by an in-hospital porter.
[assessment]
[assessment]
[assessment]
[assessment]
{drug identification}
requesting drug identification for 6 items.
the 5 items are identified as following while the other 1 item remains unknown.
Indershin (indomethacin 25mg) Anrokin (chlorzoxazone 200mg) Leflo (levofloxacin 500mg) Ketofen (ketoprofen 50mg) Decan (dexamethasone 0.75mg)
The drugs were packaged as one dose in an opaque bag, which was opened irreversibly. The checked drugs will not be returned to the ward due to the possibility of contamination.
[assessment, not posted]
[assessment]
{gastric signet-ring cell carcinoma}
[assessment]
{malignant neoplasm of unspecified site of left female breast, cT4aN3M1, stage IV}
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
The trough value of vancomycin was reported on 2022-11-10 at 25.4 mcg/mL.
A blood draw time of “2022-11-10 00:00” has been recorded, this should be due to an invalid entry, please confirm that the concentration is actually a “trough”.
Redraw the value if it is not truly a “trough”.
In the event that the value is a real “trough”, then it is recommended to hold vancomycin and perform a renal function test.
[assessment]
[assessment]
{drug identification}
requesting drug identification for 1 item.
the item is identified as Serenal (oxazolam 10mg/cap).
the drug will be sent back to ward by an in-hospital porter.
[note]
[assessment]
[assessment]
[assessment]
{colon cancer}
[assessment]
{Extranodal NK/T-cell lymphoma, nasal type, Lugano stage II, PS: 0}
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[note]
[assessment]
[assessment]
{breast cancer with brain mets}
[assessment]
[assessment]
[assessment]
This patient had received doxorubicin/cyclophosphamide (6, 2022-02-24 ~ 2022-06-07) and docetaxel (5, 2022-06-30 ~ 2022-09-01)
Brain MRI (2022-08-10) showed one solid mets increased in size and brain CT (2022-09-09) showed mild dilated intraventricular and extraventricular CSF spaces and two cystic lesions with fluid-fluid levels, about 20mm and 9.4mm in the left frontal lobe and about 44mm in the right parietotemporal lobe.
Pathology (2022-01-13) comfirmed breast cancer brain mets triple negative. Neither trastuzumab and its biosimilars/ADC(antibody drug conjugates) nor CDK4/6 inhibitors (e.g., ribociclib, palbociclib) might likely to show effective.
National Health Insurance covers PARP (poly ADP-ribose polymerase) inhibitors like olaparib and talazoparib for metastatic triple negative breast cancer with BRCA1/2 mutations since 2022-08-01.
For patients with triple-negative brain metastases from breast cancer (BCBM), two chemotherapy regimens seem to show specific CNS activity:
[assessment]
[assessment]
{ovarian cancer s/p debulking surgery}
[assessment]
2022-08
{DLBCL, diffuse large B-cell lymphoma}
[drug identification]
One drug for identification.
The drug will be sent back to ward by the in-hospital porter.
[assessment]
[assessment]
{drug identification}
Two drugs need identification.
the 2 identified items has been shown as following:
these drugs will be sent back to ward by an in-hospital porter.
{Endometrioid carcinoma, grade 2, of the uterine endometrium, AJCC Pathologic stage — pT3aN1aM1, stage IVB / FIGO stage IVB, s/p Laparoscopic gynecologic oncology staging surgery.}
[assessment]
Tube feeding is possible with all oral medications included in the active prescription.
The CNS depressant estazolam might enhance the CNS depressant effect of tramadol, so please monitor any adverse effects as always.
[assessment]
also contributes to edema formation
[assessment]
[assessment]
[assessment]
lab data
exam findings
consultation
SOP
radiotherapy
chemoimmunotherapy
[assessment]
{Gastric adenocarcinoma of antrum with gastric outlet obstruction cT3N3bM1, stage IV, ECOG 1 status post laparoscoppic gastrojejunostomy and Port-A implantation on 2022-06-16}
[assessment]
[assessment]
[assessment]
{not completed}
[assessment]
This mantle cell lymphoma patient had been treated with R-CVP/R-CHOP/R-DHAP (until April 2022) and started receiving Bruton’s tyrosine kinase inhibitor ibrutinib in early June 2022 and achieved a partial response (2022-08-19 CT). As part of this hospitalization, images will be updated.
The combination of ibrutinib and venetoclax (this is not covered by National Health Insurance at present) has been shown to promote responses in patients with relapsed or refractory mentle cell lymphoma.
[assessment]
The patient has been diagnosed with ER(+) PR(+) HER2(-) breast cancer and has been treated with letrozole, an aromatase inhibitor, in combination with the CKD4/6 inhibitor, ribociclib (2021-09-22 ~ 2022-05-25).
She was also diagnosed with EGFR Exon19 deletion, PD-L1 TPS >= 50% lung adenocarcinoma, and is currently undergoing the TKI gefitinib (2021-09-23 ~ undergoing).
The use of atezolizumab might be an option for her subsequent treatment, as her lung cancer is also characterized by PD-L1 TPS >= 50%. (2021-09-23 S2021-11626)
Her bone mets were treated with zoltedronic acid (2022-01-12, 2022-02-09) and two falling accidents were noted in July 2022. In the event that zoltedronic acid is not well tolerated by the patient, Xgeva (denosumab 120mg SC) or romosozumab (currently not available at this hospital) might be an alternative.
[assessment]
Mosarla RC, Vaduganathan M, Qamar A, Moslehi J, Piazza G, Giugliano RP. Anticoagulation Strategies in Patients With Cancer: JACC Review Topic of the Week. J Am Coll Cardiol. 2019;73(11):1336-1349. doi:10.1016/j.jacc.2019.01.017
Johnstone C, Rich SE. Bleeding in cancer patients and its treatment: a review. Ann Palliat Med. 2018;7(2):265-273. doi:10.21037/apm.2017.11.01
There has been an observation of vaginal bleeding possibly caused by bevacizumab. A transfusion might be necessary if there is a significant loss of blood (which is not the case for this patient HGB 11.0 g/dL 2022-10-06).
Tranexamic acid has not been studied in advanced cancer, but it reduces mortality due to bleeding by approximately one-third. A reduction of approximately one-third in blood loss and transfusion requirements has been seen in meta analyses of its use in elective surgery as well.
No dose-response has been seen for tranexamic acid’s therapeutic effect, and the recommended dose is 10 mg/kg per dose given intravenously every 6-8 hours, with no benefit to doses above 1 gram.
{gastric cancer with peritoneal seeding, pT4aN2M1, stage IV, (poorly cohesive carcinoma, signet-ring cell type) s/p total gastrectomy with D2 LN dissection & CCRT}
[assessment]
[assessment]
[objective]
[assessment]
Pancreatic cancer, adenocarcinoma, pT2N2M1, stage IV with liver mets with Paclitaxel and Gemcitabine Gastric cancer, adenocarcinoma, pT2N3aM0, stage IIIa Malignant neoplasm of unspecified site of left female breast
[assessment]
{HCC with lung & bone metastasis, suspected a large tumor at L5 vertebral body, R paravertebral / R perivertebral spaces}
[assessment]
[assessment]
{drug interaction}
combination use of H2 antagonist (Famotidine) and PPI (Rabeprazole) might enhance gastric acid suppression, might also increase the potential risk of Clostridioides difficile infection.
references: - https://accpjournals.onlinelibrary.wiley.com/doi/epdf/10.1002/phar.1665 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8246810/pdf/ciaa545.pdf
{colon cancer}
[objective]
[not posted?]
[assessment]
[assessment]
2022-07-29 Whole body PET scan showed the FDG avid lesions in the T1 spine, in some right paratracheal and bilateral pulmonary hilar lymph nodes, in diffuse small focal areas in bilateral lung fields and in bilateral adrenal glands are either new or more evident.
In recent months, CEA lab data showed an increasing trend
F/S blood sugar level were 200 +- 20 mg/dL, body weight loss: 57kg <- 66kg (2022-06), empagliflozin 25mg QDPC or canagliflozin 100mg QDAC might be an optional add-on.
[assessment]
{visiting the patient}
[colon cancer]
[type 2 DM]
[dyslipidemia]
[assessment]
{felt fatigue in prior chemo}
visiting the patient at 09:47 on 2021-03-15, he is wide awake, this patient has not been administrated chemo regimen yet since this admission, in prior to the chemo course, consultations for C7 spinal segment and ONJ are arranged (based on his PET scan outcome).
he says he felt fatigue after chemo been started 2-3 days in the prior course.
HbA1c 8.3% and serum glucose (AC) 191mg/dL reported on 2021-01-14, no newer data available, could be followed up if necessary.
lab data
exam finding
consultation
(C5) Deltoid/Biceps 5 4 (C6) Wrist extensor 5 4 (C7) Triceps 5 4 (C8) Flex. dig. profundus 5 5 (T1) Hand intrinsics 5 5 (L2) Iliopsoas 0 0 (L3) Quadriceps 0 0 (L4) Tibialis ant. 0 0 (L5) Ext. hallu. longus 0 0 (S1) Gastrocnemus 0 0chemoimmunotherapy
Tagrisso - osimertinib 80mg/tab 1# QD PO
Cyramza - ramucirumab (NSCLC recommended dose in package insert: in combination with erlotinib, 10mg/kg Q2W IVD 60min)
Giotrif - afatinib 30mg/tab 1# QDAC PO
[assessment]
{drug identification}
requesting drug identification for 3 items.
the 2 items are identified as following while the other 1 item remains unknown.
these drugs will be sent back to ward by an in-hospital porter.
{drug identification}
Total 3 drugs for identification.
The 2 identified items has been shown as following while the other 1 items still remain unknown:
These drugs will be sent back to ward by the in-hospital porter.
s mouth was suctioned and a 4*8 gauze was placed at the patients
throat to prevent fluid from entering patient’s airway.[note]
Locally advanced squamous cell carcinoma of the head and neck ( https://www.uptodate.com/contents/locally-advanced-squamous-cell-carcinoma-of-the-head-and-neck-approaches-combining-chemotherapy-and-radiation-therapy )
[assessment]
chemotherapy induced oral ulcer is treated with Nincort Oral Gel (triamcinolone) and hepatitis B is surpressed using Baraclude (entecavir)
{Adenocarcinoma of splenic flexure colon with obstruction, and liver, lung, bone metastasis with carcinomatosis, cT3N2bM1c, stage IVC status post colostomy on 2021-10-06}
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
{vancomycin trough concentration}
There was a trough concentration of 9.4 mg/L recorded on 2022-10-03 in this patient treated with U-Vanco (vancomycin) 1000mg QW15 (based on his renal function) since 2022-09-25.
It appeared to be effective (CRP 15.84mg/dL 2022-10-03 <= 29.58mg/dL 2022-09-22) when vancomycin was used, however, it is recommended that serum vancomycin trough concentrations should always be kept above 10 mg/L to avoid resistance development. For a pathogen with an MIC of 1 mg/L, the minimum trough concentration would have to be at least 15 mg/L to generate the target AUC (Area under the curve): MIC of 400. (ref: Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society Of Infectious Diseases Pharmacists. Clin Biochem Rev. 2010;31(1):21-24.)
Changing the current administration frequency from QW15 to QW135 is recommended to increase the concentration to at least 10 mg/L. Thank you!
BH 172, BW 109.2, BMI 36.9
past history
family history
lab data
exam finding
consultation
multiteam
surgical operation
radiotherapy
chemoimmunotherapy
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
{Primary peritoneal serous carcinoma (omentum, ileum, colon, appendix involvement), pT3cN0M0, FIGO stage IIIC s/p Optimal (R1) debulking surgery (TAH + BSO + BPLND + PALNS + OMENTECTOMY + CYTOLOGY) + CUSA + Right hemicolectomy (Terminal ileum + Appendix + ascending/transverse colon resection) on 20210111.}
[objective]
[assessment]
[assessment]
{Vulvar Cancer}
[objective]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
The blood pressure and blood sugar levels are within the normal range.
Human albumin 20g QD, furosemide 20mg QD, and spironolactone 25mg BID are currently being used to control patient edema.
Blood pressure and blood sugar are grossly in normal range.
Human albumin 20g QD, furosemide 20mg QD, spironolactone 25mg BID are currently applied to cope with the patients edema.
[assessment]
{multiple myeloma}
[assessment]
{S-colon cancer, cT3N2aM0 s/p laparoscopic anterior resection and enterolysis on 2019-09-11 s/p post-Op adjuvant chemotherapy FOLFOX finishing in 2020-04 with periotneal seeding s/p laparoscope rt diaphram tumor excision 2021-06-09}
[assessment]
[assessment]
[assessment]
[assessment]
{loss of appetite}
visiting the patient (with her daughter accompanied) at around 16:20 on 2021-08-13.
[subjective] - the patient does not feel like to eat these days.
[objective] - poor appetite, not eat much. - cachexia still in problem list.
[assessment] - chemo not applied yet since this hospitalization, not chemo induced poor appetite for sure, could be psychogenic. - psychological counselor had visited the patient on 2021-08-09. - some appetite stimulant could be of help.
[suggestion] - Megejohn (megestrol 160mg/tab) PO QD could be an option to serve as appetite stimulant. - dronabinol and oxandrolone are not available in the hospital.
{adenocarcinoma of rectosigmoid, not completed}
[subjective]
[objective]
[assessment]
2022-09-14 S-GOT/AST 43 U/L
2022-08-31 S-GOT/AST 40 U/L
2022-08-16 S-GOT/AST 33 U/L
2022-08-01 S-GOT/AST 31 U/L
2022-07-18 S-GOT/AST 27 U/L
2022-06-29 S-GOT/AST 24 U/L
2022-06-15 S-GOT/AST 20 U/L
2022-09-14 S-GPT/ALT 48 U/L
2022-08-31 S-GPT/ALT 42 U/L
2022-08-16 S-GPT/ALT 34 U/L
2022-08-01 S-GPT/ALT 34 U/L
2022-07-18 S-GPT/ALT 26 U/L
2022-06-29 S-GPT/ALT 20 U/L
2022-06-15 S-GPT/ALT 18 U/L
In the last three months, both AST and ALT have increased.
Oxaliplatin has been associated with hepatotoxicity, including elevated transaminases and alkaline phosphatases. Peliosis, nodular regenerative hyperplasia or sinusoidal abnormalities, perisinusoidal fibrosis, and veno-occlusive lesions have been detected on liver biopsy. Patients with portal hypertension or increased liver function tests, which cannot be attributed to liver metastases, should be evaluated for hepatic vascular disorders.
[assessment]
[assessment]
Hyperuricemia is noted (serum uric acid readings have been around 9mg/dL in 2022), allopurinol or febuxostat might be indicated.
Febuxostat differs from allopurinol in a number of ways:
Feburic (febuxostat 80mg/tab) 0.5# QD is recommended.
In the last half year, serum creatinine readings have been around 2 mg/dL, indicating altered kidney function. (170cm, 78kg -> eGFR 40mL/min/1.73m2, CrCl 40~45mL/min)
Fluconazole for candidiasis, prophylaxis - Hematologic malignancy patients or hematopoietic cell transplant (HCT) recipients who do not warrant mold-active prophylaxis: Oral 400 mg once daily. If the CrCl value is less than 50 mL/minute, the dosage is recommended to be reduced by 50%. The current dose is 300mg per day, which is less than 400mg, so no urgent adjustment is necessary.
As phenytoin is an inducer of CYP3A4 and P-glycoprotein and apxaban is metabolized predominantly by CYP3A4 and a P-gp substrate, the former may decrease the serum concentration of the latter.
Another direct oral anticoagulant Lixiana (edoxaban) undergoes minimal CYP metabolism (still an p-gp substrate) might be an alternative to Eliquis (apixaban). Edoxaban can be administered 30mg once daily for patients with CrCl 15 to 50 mL/minute.
As dexlansoprazole’s pharmacokinetics are not expected to be altered in patients with renal impairment, dose adjustment is not likely to be necessary.
[assessment]
Hyperuricemia is noted (serum uric acid readings have been around 9mg/dL in 2022), allopurinol or febuxostat might be indicated.
Febuxostat differs from allopurinol in a number of ways:
Feburic (febuxostat 80mg/tab) 0.5# QD is recommended.
In the last half year, serum creatinine readings have been around 2 mg/dL, indicating altered kidney function. (170cm, 78kg -> eGFR 40mL/min/1.73m2, CrCl 40~45mL/min)
Fluconazole for candidiasis, prophylaxis - Hematologic malignancy patients or hematopoietic cell transplant (HCT) recipients who do not warrant mold-active prophylaxis: Oral 400 mg once daily. If the CrCl value is less than 50 mL/minute, the dosage is recommended to be reduced by 50%. The current dose is 300mg per day, which is less than 400mg, so no urgent adjustment is necessary.
As phenytoin is an inducer of CYP3A4 and P-glycoprotein and apxaban is metabolized predominantly by CYP3A4 and a P-gp substrate, the former may decrease the serum concentration of the latter.
Another direct oral anticoagulant Lixiana (edoxaban) undergoes minimal CYP metabolism (still an p-gp substrate) might be an alternative to Eliquis (apixaban). Edoxaban can be administered 30mg once daily for patients with CrCl 15 to 50 mL/minute.
As dexlansoprazole’s pharmacokinetics are not expected to be altered in patients with renal impairment, dose adjustment is not likely to be necessary.
[assessment]
{Mucinous adenocarcinoma of the sigmoid colon with uterus invasion, stage pT4bN2bM0, stage IIIC, s/p LAR in 2017, with local regional recurrence s/p concurrent chemoradiotherapy}
[assessment]
Losartan might be held temperately due to a drop in blood pressure (2022-09-20 09:21 96/56mmHg).
Blood glucose levels were elevated (2022-09-20 06:40 236 mg/dL). If the reading remains high over the next two days, then antiglycemic interventions might be necessary.
[Chief Complaint] for chemotherapy
[Present Illness] This 46-year-old female patient had invasive carcinoma of no special type with focal micropapillay pattern of the right breast cancer, pT2N1M0, stage IIB, ER (postive, +++95%), RP (postive, +++80%), Her-2/Neu(equivocal, 2+), s/p MRM and ALND on 2017/11/30, post chemotherapy with AC 4 times since 106/12-107/03/13. Adjuvant chemotherapy with Taxotere on 108/04/04-6/6 and radiotheratpy.
On 2020/12/01, microinvasive carcinoma of the left breast, AJCC 8 th edition, Pathology stage: pT1miN0; Anatomic stage IA; Prognostic stage IA if cM0. Margins: Negative, Closest margin (7 mm from deep margin). ER (Ab): Positive (60%, moderate intensity), PR (Ab): Negative, HER-2/Neu (Ab): Positive (score= 3+), s/p left partial mastectomy and sentinel lymph node biopsy, radiotherapy (Radiotherapy with 5000cGy/25 ractions of the left breast, and 6000cGy/30 fractions of the left breast tumor bed (scar) area), and status during endocrine therapy.
Followed CT on 2022/1/28 which revealed Four Metastases on both hepatic lobes are highly suspected. Her-2 overexpressed liver metastases were confirmed after liver biopsy. Bone scan revealed a hot spot in the left humeral head, some faint hot spots in bilateral rib cage, upper T-spine, L2-3 spines, lower L-spine, sacrum, bilateral sternoclavicular junctions, upper portion of the sternum, shoulders, and knees in whole-body survey.
Then she recevied C1 Herceptin, Perjenta (840mg) for loading dose on 2022/2/14, Taxotere on 2022/2/15. C2 Herceptin, Perjenta on 2022/3/7 Taxotere on 2022/3/8. C3 Herceptin, Perjenta on 2022/3/28 Taxotere on 2022/3/29. C4 Herceptin and Perjenta on 2022/4/18,Taxotere on 2022/4/19. Followed CT of chest was performed on 5/2 revealed almost resolution of metastatic hepatic tumors (with a small residual lesion in S6) compared with abdominal CT on 1/28.minimal nonspecific RML inflammation and subtle small nodules inlower lobes of lungs, susggest f/u. Chemotherapy with C5 Herceptin + Perjenta (420mg) on 2022/5/9.Taxotere on 2022/5/10. C6 Herceptin + Perjenta (420mg) on 2022/5/30.Taxotere on 2022/5/31 C7 Herceptin + Perjenta (420mg) on 2022/6/20.Taxotere on 2022/6/21 C8 Herceptin + Perjenta (420mg) on 2022/7/11.Taxotere on 2022/7/12.
Followed up CT of chest on 2022/8/8 revealed 1.almost resolution of metastatic hepatic tumors (with a small residual low lesion in S6) compared with CT on 5/4 and 2.two small nodules in Rt lung still visualized, susggest f/u.
C9Herceptin + Perjenta (420mg) on 2022/8/29 and Taxotere on 2022/8/30
This time, she was admitted for chemotherapy on 2022/9/18.
{poorly differentiated squamous cell carcinoma of esophagu, cT3N2M0 stage III; poorly differentiated adenocarcinoma of stomach with liver metastases, cT3N0M1, stage IV}
[assessment]
[assessment]
{Olfactory Neuroblastoma}
[note]
[assessment]
[drug identification]
[assessment]
[Angiotensin-Converting Enzyme Inhibitors / Angiotensin II Receptor Blockers]
[assessment]
[not completed]
[assessment]
[tube feeding]
The capsule of Nexium (esomeprazole 40mg/tab) should be opened and the small granules poured into drinking water before tube feeding can begin.
[objective]
[assessment]
CEA lab data
According to CT scan impressions, the disease had responded to the current treatment (bevacizumab + FOLFIRI) introduced in early March 2021 and remains stable in the recent half year. However, CEA readings have also increased over the past 12 months.
Upon confirmation that the disease has acquired resistance, regorafenib might be considered as a subsequent treatment option.
The underlying condition HTN appears to be well controlled during this hospitalization. There are no updated hyperlipidemia lab results available for the past two years that could be ordered if clinically indicated.
[assessment]
{Rectal Cancer}
[initial presentation]
[definite diagnosis]
[disease extent]
[treatment]
[effect and side effect]
[ongoing problem]
Objective:
Assessment:
Suggestion:
Objective:
Assessment:
Suggestion:
Objective:
Assessment:
Suggestion:
[assessment]
Serum uric acid lab data
There is a history of gout in this patient, and his serum uric acid level is elevated. One option might be to prescribe Feburic (febuxostat 80mg) 0.5# QD for at least seven days.
Lab data: serum creatinine (2022-09-13 2.14 mg/dL <- 2022-09-01 1.20 mg/dL), BUN (2022-09-13 39 mg/dL <- 2022-09-01 23 mg/dL). The patient’s renal function is declining.
Male, age 58, 160cm, 45kg => BMI 17.6kg/m2, CrCl 24mL/min, eGFR 32~38mL/min/1.73m2
As this patient is mildly thin, an increase in intake is recommended in order to prevent malnutrition and build up some reserve for future treatment.
The use of carboplatin has been associated with renal adverse reactions, including decreased creatinine clearance (27%), and increased blood urea nitrogen (14% to 22%). In the next chemotherapy cycle, it might be an option to reduce the dose.
{not completed}
[assessment]
The patient’s blood pressure has been around 190(+-10)/90(+-10), despite taking the following antihypertensive agents as part of the active prescription:
Clonidine can be used for chronic hypertension as an alternative agent. It is not recommended for initial management but may be considered as additional therapy for resistant hypertension in patients who do not respond adequately to combination therapy with preferred agents (ACC/AHA [Whelton 2018]). We have in stock Catapres (clonidine 0.075mg) currently. Oral form immediate release: Initial 0.1 mg twice daily; increase dose in increments of 0.1 mg/day at weekly intervals based on response and tolerability; usual dose range: 0.2 to 0.6 mg/day in 2 divided doses. The manufacturer’s labeling includes a maximum daily dose of 2.4 mg; however, doses >0.6 mg/day are generally not used.
In an alternative attempt to lower the blood pressure, currently used Sevikar might also be replaced with Adapine (nifedipine 30mg) 1# BID and Micardis (telmisartan 80mg) 1# QD.
Minoxidil (not available in stock) can also act as an alternative adjunctive agent. It should be reserved for patients with resistant hypertension who do not respond adequately to an optimized 4-drug regimen, ideally consisting of a thiazide-like diuretic (eg, chlorthalidone) and a mineralocorticoid-receptor antagonist (eg, spironolactone). It can be used in combination with a beta-blocker to prevent reflex tachycardia. Fluid retention may occur and may require additional diuretic therapy (ACC/AHA [Whelton 2018]; Brook 2022). Oral form initial: 5 mg once daily, increase dose gradually in intervals of >= 3 days; usual effective dose: 10 to 40 mg/day in 1 to 3 divided doses; maximum dose: 100 mg/day in 1 to 3 divided doses. During therapy, if supine diastolic pressure is reduced <30 mm Hg, administer total daily dose once daily; if supine diastolic pressure is reduced >30 mm Hg, administer in divided doses (ACC/AHA [Whelton 2018]; manufacturer’s labeling).
[assessment]
[assessment]
Alprazolam is metabolized by the enzyme CYP3A4 and the antifungal drugs itraconazole, ketoconazole, posaconazole, and voriconazole are strong inhibitors of this enzyme, which can increase the serum concentration of alprazolam.
Each member of the azole class exhibits a unique spectrum of activity, although fluconazole, itraconazole, voriconazole, posaconazole, and isavuconazole all demonstrate similar activity against most Candida species. (ref: Pappas PG, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;62(4):e1-e50. doi:10.1093/cid/civ933 )
While fluconazole is a less strong (i.e. moderate) CYP3A4 inhibitor than voriconazole, it might be a suitable substitute for voriconazole if no other considerations are taken into account. Additionally, a change from 2# to 1# of alprazolam might also be considered.
[assessment]
On 2022-09-05, blood was drawn about one hour before the time of administration for cyclosporine TDM. It is recommended that blood be drawn within half an hour of the time of administration. As of the latest monitoring result, the level is 193.8 ng/mL, which is generally considered to be within the reasonable range (100 to 400 ng/mL). Based on changes in serum creatinine, renal function appears to be slowly declining (but still within normal range). It might take less time to achieve a concentration greater than 400ng/mL by consecutive daily doses of 200mg than it did in mid-July. A retest is recommended after three days to determine if the dose should be adjusted.
Time serial serum creatinine, cyclosporine trough concentration and cyclosporine daily dose log:
{recommended cyclosporine daily dose to maintain a stable and reasonable trough concentration}
{cyclosporine concentration}
{cyclosporine trough concentration}
{post-transplant immunization}
{cyclosporine trough concentration}
As of 2022-07-14, the trough concentration of cyclosporine was 162 ng/mL, which is considered to be an acceptable level.
{Cyclosporine trough concentration follow-up}
{Cyclosporine (ciclosporin) concentration}
{cyclosporine trough concentration}
{MDS, RAEB-1}
[assessment]
Dosage of ATG as part of the conditioning regimen in allogeneic PBSCT from matched sibling donors in patients with hematologic malignancies
[assessment]
[assessment, not posted]
[assessment]
[assessment]
[assessment]
{tube feeding}
[objective]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
Patients with acute portal vein thrombosis should be started on low molecular weight heparin to achieve rapid anticoagulation, with a switch to an oral anticoagulant (warfarin or possibly a direct-acting oral anticoagulant [DOAC]) once the patient’s condition has stabilized and no invasive procedures are planned.
Patients with chronic portal vein thrombosis when treated with anticoagulation, enoxaparin is more often used rather than warfarin because of its shorter duration of action, less variability in anticoagulation, decreased need for monitoring, and decreased difficulty when managing patients around the time of liver transplantation. An alternative is to use an oral anticoagulant.
If warfarin is used, goal INR can be set as 2 to 3. (2022-08-03 INR 1.24)
Enoxaparin (in active prescription now) used for venous thromboembolism treatment in patients with active cancer:
Direct oral anticoagulant (DOAC) therapy is an alternative to enoxaparin or warfarin for treating chronic portal vein thrombosis.
Apixaban oral 10 mg twice daily for certain duration followed by 5 mg twice daily.
[assessment]
{Lung cancer at right lower lung, adenocarcinoma, with multiple brain metastasis, cT4N0M1b, stage IV, with mukltiple brain metastasis, PD-L1: TC < 1%, IC < 1%, TPS < 1 %, EGFR E19 deletion and T790M (+)}
[assessment]
[assessment]
[assessment]
[note]
{hypopharynx squamous cell carcinoma, cT3N1M0}
[assessment]
{Rt breast cancer with Rt axillary LNs, lungs, and liver metastases}
[objective]
[assessment]
{Rt breast cancer with Rt axillary LNs, lungs, and liver metastases}
[objective]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
{autologous Peripheral Blood Stem Cell Transplantation}
chemotherapy with Mabthera on 12/27,Etoposide 500mg/m2 total given 963mg Q12H on 12/28-30 followed by PBSC harvest,GCSF 300mcg QD on 12/31-1/14.Port-A removal on 2022/1/14.
[preparation and administration of mesna]
[Teicoplanin Dose]
blood creatinine readings reported:
2022-01-10 1.64mg/dL 2022-01-08 1.83mg/dL 2022-01-06 1.72mg/dL 2022-01-03 1.31mg/dL
teicoplanin has been administered since 2022-01-06, the elevated serum creatinine maintains stable for half week, no dose adjustment needed for now, keep monitoring renal function as regular.
{DLBCL}
{DLBCL stage IV}
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
{oropharyngeal cancer}
{rectal cancer with LNs, lung, sacrum, sacroiliac joints mets, stage IV}
[objective]
[assessment]
[assessment]
{angioimmunoblastic T cell lymphoma, high grade with neck, inguinal, retroperitoneal LN metastases and generalized skin rashes, Lugano stage III, PS:0}
{Cholangiocarcinoma, pT4N0cM0, s/p S5 segmentectomy with lymph node dissection and cholecystectomy on 2020-01-13, with T11-12 metastasis and compression fracture s/p radiotherapy to T spine in 2020-04}
[assessment]
[assessment]
[assessment]
[assessment]
[note]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
{Neuroendocrine carcinoma}
2022-08-09 Creatinine 1.66 mg/dL
2022-08-03 Creatinine 1.72 mg/dL
2022-07-27 Creatinine 1.69 mg/dL
2022-07-14 Creatinine 1.56 mg/dL
2022-06-28 Creatinine 1.61 mg/dL
2022-06-17 Creatinine 1.28 mg/dL
2022-06-02 Creatinine 1.50 mg/dL
2022-05-26 Creatinine 1.31 mg/dL
2022-05-16 Creatinine 1.17 mg/dL
2022-05-13 Creatinine 1.17 mg/dL
2022-05-09 Creatinine 1.45 mg/dL
2022-04-28 Creatinine 1.45 mg/dL
2022-04-18 Creatinine 1.55 mg/dL
2022-04-06 Creatinine 1.16 mg/dL
2022-03-24 Creatinine 1.45 mg/dL
2022-03-12 Creatinine 0.95 mg/dL
2022-02-21 Creatinine 1.05 mg/dL
2022-08-09 BUN 41 mg/dL
2022-08-03 BUN 39 mg/dL
2022-07-27 BUN 38 mg/dL
2022-07-14 BUN 40 mg/dL
2022-06-28 BUN 24 mg/dL
2022-06-17 BUN 25 mg/dL
2022-06-02 BUN 24 mg/dL
2022-05-26 BUN 33 mg/dL
2022-05-16 BUN 16 mg/dL
2022-05-13 BUN 13 mg/dL
2022-05-09 BUN 32 mg/dL
2022-04-28 BUN 34 mg/dL
2022-04-18 BUN 28 mg/dL
2022-04-06 BUN 17 mg/dL
2022-03-24 BUN 26 mg/dL
2022-03-12 BUN 15 mg/dL
2022-02-21 BUN 16 mg/dL
[assessment]
{Right upper lung adenocarcinoma, moderately differentiated with bone metastasis, stage IV}
[assessment]
[assessment]
{ovarian cancer, pT3aN0cM0, FIGO stage IIIA2}
[assessment]
{newly diagnosed with Endometrioid adenocarcinoma T1BN0M0 stage IB s/p Laparoscopic gynecologic oncology staging surgery}
[objective]
[assessment]
[assessment]
[assessment]
[assessment]
{Nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and Rt retropharyngeal LAP metastasis s/p concurrent chemoradiotherapy on 2012/9/17 s/p 2nd PF on 2012/11/30}
[assessment]
[assessment]
[assessment]
{lung adenocarcinoma and esophageal adenocarcinoma}
[Past History]
[note]
[assessment]
{prevent the patient from potential drug interaction: Dasatinib / Inhibitors of the Proton Pump (PPIs and PCABs)}
[assessment]
[assessment]
[note]
[assessment]
[assessment]
[objective]
[assessment]
{colon cancer with liver mets}
[objective]
[assessment]
{colon cancer with liver mets}
[objective]
[assessment]
[assessment]
[objective]
[assessment]
[assessment]
{Small Lymphocytic Lymphoma}
[objective]
[assessment]
[assessment]
[assessment]
{left pyriform sinus cancer, cT2N2bMx, stage IVA, brain mets}
[assessment]
[assessment]
{cervical cancer, adenocarcinoma, cT1bN1MB, FIGO stage IIIB}
[assessment]
{BFluid - the amount of electrolyte can be added}
A supplement to my explanation after answering the nurse’s call this morning about the compatibility of B Fluid with KCl.
{High grade serous carcinoma FIGO stage IIIC, right ovarian cancer with peritoneal seeding s/p operation}
[note]
Ovarian Cancer Continue Including Fallopian Tube Cancer and Primary Peritoneal Cancer, NCCN Evidence Blocks, Version 1.2022 - January 18, 2022, p42,43
[assessment]
[assessment]
{Thymic cancer, squamous cell carcinoma, cT4N2M1b, stage IVB, with malignant pleural effusion, bone and lung metastasis}
[note]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
{visiting}
[assessment]
Dose adjustment recommendation for the scheduled PBSCT in this impaired renal function patient
{pancreatic head carcinoma, cT4N0M0, stage III, Dx in June 2022, obstructive jaundice s/p PTGBD on 20220613}
[note]
[assessment]
[assessment]
{T-cell lymphoma with bone invasion, stage IV}
[note]
The disease should be subtype Peripheral T-cell lymphoma (PTCL), not otherwise specified (NOS)?
T-Cell Lymphomas NCCN EB Version 2.2022 - March 7, 2022, p13
Restage after 3-4 cycles with PET/CT (preferred) or C/A/P CT scan with contrast
Recommended Adult Immunization Schedule — United States, 2012 ( https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6104a9.htm )
[to be discussed]
[assessment]
[assessment]
{pancreatic neck adenocarcinoma,cT1cNXM1, stageIV, with retroperitoneal spread status post Roux-en-Y hepatico-jejunostomy and cholecystectomy}
[objective]
[assessment]
[assessment]
[assessment]
{DLBCL}
[assessment]
{Left overain cacner, High grade serous carcinoma, with liver mrtastasis, s/p Debulking surgery}
{Endometrium neuroendocrine carcinoma, pT2pN0M0, FIGO stage II s/p Staging surgery(ATH + BSO + omentectomy + LN dissection) on 2022/02/14}
[objective]
[assessment]
[assessment]
{Pancreatic adenocarcinoma, T4N1M0, stageIII}
[assessment]
[assessment]
[assessment]
{cholangiocarcinoma, recurrenct, liver and lung mets, s/p colon cancer}
[objective]
[assessment]
[assessment]
[assessment]
{right ovarian cancer, pT1c3N0 if cM0, FIGO IC3 s/p Op on 20200720}
[note]
[assessment]
[assessment]
{intra-hepatic cholangiocarcinoma with lung and right adrenal mets}
[assessment]
[assessment]
{valganciclovir not for herpes}
{pseudomyxoma peritonei}
[assessment]
{CNS DLBCL}
[objective]
[assessment]
{CNS DLBCL}
[objective]
[assessment]
{CNS DLBCL}
[objective]
[assessment]
[assessment]
{hyperglycemia}
[objective]
[assessment, suggestion]
[objective]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
{alpha-fetoprotein-producing esophageal adenocarcinoma with liver metastasis, T4N2M1 stage IVB}
[memo]
[assessment]
[assessment]
[objective]
[assessment]
[assessment, suggestion]
{multiple myeloma}
{gastric cancer with colon mets s/p subtotal gastrectomy and partial T-colectomy}
[subjective]
[objective]
[assessment]
[assessment]
{high grade B-cell lymphoma}
[objective]
[assessment]
[assessment]
{cyclosporine-A TDM}
{Minutes of the Interprofessional Practice Meeting and Family Meeting}
{Interprofessional Practice Meeting and Family Meeting following up}
{follicular lymphoma}
[assessment]
{steroid conversion}
An approximate corticosteroid dosing conversion
[assessment]
{potential drug interactions}
{tachycardia}
[assessment]
[assessment]
700526699
{drug identification}
Total 14 drugs for identification.
The 10 identified items has been shown as following while the other 4 items still remain unknown:
These drugs will be sent back to ward by the in-hospital porter.
{upper GI bleeding}
[assessment]
{small bowel ileus}
[assessment]
[assessment]
[assessment]
[assessment]
Harnalidge (tamsulosin) 0.4mg PO QDAC should be replaced with Urief (silodosin) 8mg PO QD as a preferred alternative.
[assessment]
{mediastinum small cell carcinoma with pericardial effusion with SVC syndrome, stage IV}
[objective]
[assessment]
[assessment]
[objective]
[assessment]
[assessment]
[assessment]
[assessment]
[objective]
[assessment]
[objective]
[assessment]
[objective]
[assessment]
[objective]
[assessment]
[objective]
[assessment]
{ovarian clear cell carcinoma stage IA}
[objective]
[assessment]
[assessment]
{ovarian clear cell carcinoma stage IA}
[objective]
[assessment]
[objective]
[assessment]
He was admitted for hemoptysis with blood clot from oral and nasal cavity for more than a week. History of NPC and CT imaging revealed possible tumor recurrence in Jan 2022.
[objective]
[assessment]
[objective]
[assessment]
[assessment]
[objective]
[assessment]
[objective]
This 43 years old female patient has the history of: 1) Chronic kidney disease for 10 years; 2) Ulcerative colitis with medical treatment for 20 years; 3) Fourth degree hemorrhoids status post hemorrhoidectomy on 20210623; 4) Left arteriovenous fistula on 20220124.
diagnosis
exam finding
lab data
surgical operation
[assessment]
This patient has CKD stage 5 adminitted on 2022-04-29
CKD stage 5, high Creatinine, high BUN, high phosphorus, low calcium, low bicarbonate normal CRP and WBC AV shunt
[objective]
[assessment]
[assessment]
{synchronous double (breast and colon) primary tumors s/p MRM s/p hemicolectomy}
[objective]
[assessment]
[assessment]
{synchronous double (breast and colon) primary tumors s/p MRM s/p hemicolectomy}
[objective]
[assessment]
{synchronous double (breast and colon) primary tumors s/p MRM s/p hemicolectomy}
[history]
[definite diagnosis, disease extent]
[treatment]
[assessment]
[assessment]
[objective]
[assessment]
[assessment]
[assessment]
{esophageal squamous cell carcinoma with liver and lung mets}
[objective]
[assessment]
[objective]
[assessment]
[objective]
[assessment]
{ovarian cancer}
[assessment]
[comment]
[comment]
[objective]
[assessment]
[objective]
[assessment]
{tube feeding}
[objective]
[assessment]
{Recurrent hepatocellular carcinoma with Lung and C-spine, T-spine and L-spine metastasis cT2N0M1 stage IV}
[objective]
[assessment]
{tube feeding}
{Acute myeloid leukemia}
[objective]
[assessment]
{Quinolones-Antacids Interactions}
[objective]
[assessment]
[suggestion]
{Interprofessional Practice Meeting and Family Meeting}
{mesna administration}
[objective]
[assessment]
[objective]
Creatinine lab data: - 2022-01-10 1.25mg/dL - 2022-01-07 1.43mg/dL - 2022-01-03 0.93mg/dL
[assessment]
[suggestion]
[objective]
[reference]
[assessment]
{Left renal cell carcinoma with metastatic mediastinal lymphadenopathies and suspecious RUL lung metastasis, liver and bone metastases s/p chemotherapy and radiotherapy}
[objective]
[assessment]
{RCC with multiple bone metastases}
[objective]
[assessment]
{Recurrence nasopharyngeal carcinoma with skull base destruction and cranial nerve (V2, VI) invasion , liver metastasis and multiple lung metastases in progression.yT4N2M1,stageIVB}
[objective]
[assessment]
{rectal cancer with liver mets s/p LAR and liver partial resection}
[objective]
exam finding
lab data
surgical operation
chemoimmunotherapy
[assessment]
[objective]
[assessment]
{Acute myeloblastic leukemia, not having achieved remission}
[objective]
[assessment]
{compatibility}
The combination of calcium gluconate, magnesium sulfate, and potassium chloride in 0.9% sodium chloride normal saline is compatible.
Lab data reported on 2022-01-10 - RBC 3.44*10^6/uL - HGB 9.4g/dL
Danol (Danazol) androgen is prescribed to pause menses to maintain RBC, HGB levels in the setting of chemotherapy.
{rectal cancer cT2N1bM0 stage IIIA}
[subjective]
[objective]
[assessment]
{rectal cancer}
[initial presentation]
[definite diagnosis]
[disease extent]
[treatment & plan]
[effect & side effect]
[ongoing problem]
[assessment]
{hepatic failure, cirrhosis of liver, hepatorenal syndrome, esophageal varices, gastric varices, ascites, type 2 diabetes ellitus, hyperlipidemia, anemia}
[objective]
[assessment]
{ovary cancer s/p oophrocystectomy}
[objective]
[assessment]
{pancreatic cancer T4N1M0 stage III}
[objective]
[assessment]
[objective]
[assessment]
[objective]
[objective]
[assessment]
[objective]
[assessment]
{hypopharyngeal and supraglottic cancer, cT4bN2b cM0, stage IV with recurrent lung mets, progression of mets pulmonary lesions and mediastinal/hilar LAP}
[objective]
[assessment]
[assessment]
[objective]
[assessment]
{Malignant neoplasm of rectosigmoid junction, stage cT3N0M0, stage IIA}
[objective]
[assessment]
{Malignant neoplasm of rectosigmoid junction, stage cT3N0M0, stage IIA}
[objective]
[assessment]
[objective]
[assessment]
{Peripheral T-Cell Lymphoma, PTCL, relapsed}
[objective]
[assessment]
{Nasopharyngenl Carcinoma - NPC, non-keratinizing carcinoma}
[objective]
[assessment]
[objective]
[objective]
[subjective]
[objective]
{rt breast ca (TNBC), cT2N0M0 stage IB}
[assessment]
[subjective]
[objective]
[assessment]
{Compatibility for both Tapimycin and KCl in Suntose}
{Panceratic carcinoma, cT1N1M1 (left neck subclavicle mets), stage IV}
[objective]
[assessment]
[objective]
[assessment]
{tube feeding}
the oral drugs in active medication including: - keto (ketorolac 10mg) - neurontin (gabapentin 100mg) - tramacet (tramadol 37.5mg, acetaminophen 325mg)
all the above drugs can be grinded and administrated via NG tube
[objective]
[assessment]
{myelodysplastic syndrome}
[objective]
[assessment]
[objective]
[assessment]
{lowering BP gently}
visiting the patient at around 16:45 on 2021-08-30, he did not complain of discomfort or unwellness these days, however he shared his experience of dizziness and fainting when SBP below 160mmHg since years ago. lowering blood pressure should be in a gentle way.
{Low HGB, HTN, ESRD}
[objective]
[assessment]
[suggestion]
{bladder cancer with lung mets}
[definite diagnosis]
[treatment]
[assessment]
[suggestion]
{SCC of tongue, cT4N1M0, s/p total glossectomy, right mandibular osteotomy, right marginal mandibulectomy, selective neck dissection, wide excision of malignant left lower gum SCC and marginal mandibulectomy, teeth extraction of #46, tracheotomy and free flap reconstruction}
[objective]
{gastric cancer, stage IIA, extra-capsular spread (ECS) positive}
[objective]
[assessment]
[objective]
[assessment]
[objective]
{Thalidomide/Dexamethasone Interaction}
Dexamethasone might enhance the dermatologic adverse effect and/or thrombogenic effect of Thalidomide.
Consider using venous thromboembolism prophylaxis in patients with multiple myeloma who are receiving both thalidomide and dexamethasone, particularly if the patient is newly diagnosed or has other risk factors for thromboembolism. Low-molecular-weight heparin or warfarin (at INR of 2.0-3.0) have been proposed as reasonable prophylactic agents. Regarding the potential dermatologic interaction between thalidomide and dexamethasone, monitor for any evidence of dermatologic events, particularly maculopapular or erythematous rash. If evident, discontinuation of drug therapy or dosage reduction may be required.
{possible drug interaction: Dasatinib / Histamine H2 Receptor Antagonists}
[objective]
[assessment]
[suggestion]
{marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)}
[objective]
[assessment]
COPD is listed as one of the diagnoses (but not in current problem list) in this hospitalization, however no corresponding medication prescribed yet.
Some bronchodilators such as beta agonists, antimuscarinic agents, or methylxanthines might be considered later after other acute symptoms mitigated.
[objective]
[assessment]
{marginal zone lymphomas}
[objective]
[assessment]
This 92-year-old woman diagnosed by NTUH in 2021 Dec wtih advanced ascending colon cancer with lung, paraaortic LN, peritoneal carcinomatosis, cT4aN2bM1c, stage IVC.
Take into account of the patient’s age, intensive therapy might not be most appropriate, a vanilla regimen like FOLFOX could be a candidate for systematic treatment.
KRAS, NRAS, BRAF, HER2, MSI/MMR, NTRK fusion, dihydropyrimidine dehydrogenase test might be ordered optionally if related data from NTHU is not anticipated.
{lung cancer with bone and brain metastasis}
[objective]
[assessment]
{consultation record}
[Brief History and Clinical Findings]
for suspect multiple myeloma, metastases
This 49-year-old female was Dx (1) Leukocytosis, suspect intra abdominal infection (2) Suspect multiple myeloma, metastases (3) Hypertension (4) Fracture of 7th ribs in 2020-12. This time, she was admission because bilateral lower leg edema for two days. She complained for lower back pain while mobile and right back sorenss for 3 months and subside while lying down. She has suffered from fracture of left 7th rib and right little toe pain and local redness. According to the patient, she has visited Ortho OPD and Rheumatology OPD for the recurrent multiple joint pain. She came to our ER. CT image revealed retroversion of uterus with tumors (up to 6.3cm) suspected myomas and Multiple osteolytic lesions at bony structures. DDX: multiple myeloma, metastases. Please evaluation her condition by your expertise. Thank you very much.
[Consultation Findings and Recommandations]
Patient examined and Chart reviewed. A case of multiple bony destruction is noted. I am consulted for the possible etiolgy.
My suggestions: - Complete CT scan work-up e.g., Chest CT, to rule out CEA-elevated lung cancer or CEA/CA153-elevated breast cancer - Please survey breast conditin, using breast sono and/or mammography to rule out CEA/CA153-elevated breast cancer - Please check Protein EP/IFE, kappa/lambda chain to rule out myelopma or light chain disease - Please perform EGD and colonoscopy to rule out CEA-elevated GI cancer - If no clue from the afroementioned examinations, bone marrow biopsy is mandatory.
{drug identification}
requesting drug identification for 6 items.
the 4 identified items has been shown as following while the other 2 items still remain unknown: - Megajohn - megestrol 160mg - Kentamin - thiamine 50mg, pyridoxine 50mg, cyanocobalamin 500mcg - Romicon-A - lysozyme 20mg, dextromethorphan 20mg, cresolsulfonate 90mg - Olmetec - olmesartan medoxomil 20mg
these drugs will be sent back to ward by an in-hospital porter.
[objective]
This is a patient diagnosed by TSGH with poorly differential gastric adenocarcinoma with carcinomatosis and metastatic lymphadenopathy and bone metastasis, cT4aN3aM1, stage IV, seeking for second opinion on 2022-01-21.
[Assessment]
Diagnosis: Splenic flexure colon obstruction and massive ascites suspected carcinomatosis status post T-loop colostomy on 2021-08-27.
2021-08-30 Patho - omentum tumor, extensive resection
2021-08-25 Patho - colorectal polyp
Medication
[objective]
[assessment, suggestion]
no drug allergy recorded in database.
CBC reported on 2022-01-18 showed items below normal ranges:
no liver or kidney dysfuncion shown in recent lab data.
the drugs prescribed at neurology OPD have been included in active medication, no issue found.
CBC reported on 2022-01-18 showed items below normal ranges:
no drug allergy recorded in database.
no liver or kidney dysfuncion shown in recent lab data based on AST, ALT, BUN, Creatinine, eGFR.
no issue found in active medication.
[objective]
Lab data - Free T4 - 2022-01-14 2.26ng/dL (normal 0.58~1.35) - 2021-10-05 1.94ng/dL - TSH - 2022-01-14 0.027uIU/mL (normal 0.38~5.33) - 2021-10-05 <0.005uIU/mL
PE - body weight - 2022-01-14 65kgw - 2022-01-09 68kgw
Medication - Eltroxin (levothyroxine 50mcg/tab) #1 BIDAC
[assessment]
[suggestion]
[objective]
[assessment]
[suggestion]
{hyponatremia, hypoosmolality}
[objective]
[assessment]
[suggestion]
[initial presentation]
[definite diagnosis & disease extent]
[plan & treatment]
[effect & side effect]
[ongoing problem]
{Diffuse Large B Cell Lymphoma}
[objective]
[assessment]
[suggestion]
CT and MRI on 2022-01-05 suggested possible malignant tumor in the right adrenal gland measuring 8.2 x 10 x 9 cm.
Chromogranin A 918ng/mL, ACTH < 5g/mL
lab data in early Jan 2022 did not backup hyperaldosteronism, hypercortisonlemia (i.e. both in normal range).
hypertenstion and/or tachycardia might have been mitigated by Concor (bisoprolol), higher readings of blood sugar (since mid Dec 2021) might have been reduced by Galvus Met (vildagliptin + metformin), these symptoms could be caused by neuroendocrine tumors.
{Cancer of Unknown Primary}
[Objective]
Lab data reported on 2022-01-10 and some prescribed medication: - CRP 9.17mg/dL (normal <1), WBC 166*10^3/uL (normal 3.9~10.6) <= Tapimycin (Piperacillin + Tazobactam) - Blood Uric Acid 16.3mg/dL (normal 4.4~7.6) <= Fasturtec (Rasburicase) - Calcium 4.04 mmol/L (normal 2.2~2.65) <= Miacalcic (Calcitonin) - Magnesium 1.4mg/dL (normal 1.9~2.7) - Triglyceride (TG) 524mg/dL (normal <150), HDL-C 5mg/dL (normal >40) - Benz(BZO) intoxication positive (normal negative)
[Assessment/Suggestion]
[Objective]
[Assessment]
[Suggestion]
High Serum glucose 235mg/dL (2022-01-05), Lactic Acid 4.9mmol/L (2022-01-06), NAKO NO.5 500mL IVD BID and Saline 500mL IVD QD are prescribed.
High CRP 13.47mg/dL (2022-01-05), Procalcitonin (PCT) 8.37ng/mL (2022-01-06) suggest (probable bacterial) infectious process with systemic consequences. Tapimycin and Targocid are prescribed.
Objective:
Assessment:
Suggestion:
{drug identification}
requesting drug identification for 7 items.
the 3 identified items has been shown as following while the other 4 items still remain unknown:
Utapine F.C. Tablet (quetiapine fumarate 25mg) - bipolar disorder, schizophrenia
Zoloft F.C. Tablet (sertraline hydrochloride 50mg) - major depressive disorder (unipolar), obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder, premenstrual dysphoric disorder, social anxiety disorder
Anxiedin Tablet (lorazepam 0.5mg) - anxiety
these drugs will be sent back to ward by the in-hospital porter.
{drug identification}
requesting drug identification for 13 items.
the 9 identified items are listed as following, however, the other 4 items still remain unknown:
these drugs will be sent back to ward by the in-hospital porter.
{potential drug interactions, vitamin supplement}
[objective]
[assessment]
[suggestion]
thanks and regards,
{dedifferentiated liposarcoma}
[tube feeding]
[objective]
[assessment]
{mesna compatibility for common solutions}
reply for the consultation from the ward, mesna is compatible with: - D5W (Dextrose 5% in water) - D5NS (Dextrose 5% in sodium chloride 0.9%) - D5W - 1/2 NS (Dextrose 5% in sodium chloride 0.45%) - NS (Normal saline (Sodium chloride 0.9%)) - Lactated Ringer’s Injection
{post IPP meeting following up}
[busulfan inventory]
[preparation and administration precautions]
[underlying diseases]
[medical compliance]
{hypoalbuminemia and proteinuria caused by UTI induced nephrotic syndrome?}
[tube feeding]
[objective]
[assessment]
[suggestion]
[tube feeding]
[iron supplement]
[drug interaction]
[objective]
[assessment]
[suggestion]
{ovary cancer s/p debulking surgery}
[history]
[initial presentation]
[definite diagnosis, disease extent]
[treatment]
[assessment]
{unresectable liver tumor}
[initial presentation]
[definite diagnosis, disease extent]
[underlying disease]
[assessment]
{colon cancer with suspected liver mets and peritoneal seeding}
[initial presentation]
[definite diagnosis, disease extent]
[assessment]
{hypophosphatemia, hypokalemia}
[objective]
[assessment]
[suggestion]
{UTI, hypoalbuminemia}
[objective]
[assessment, suggestion]
{esophageal scc with lung and stomach mets}
[definite diagnosis, disease extent]
[treatment]
[assessment]
{duplicated NSAIDs}
[objective]
[assessment]
[suggestion]
{potential drug interaction}
[objective]
[assessment]
[suggestion]
{breast cancer}
[initial presentation]
[definite diagnose, disease extent]
[treatment]
[assessment]
{tube feeding}
meitifen (diclofenac Na 75mg) PO QD which is controlled-release design might be changed to defram-k (diclofenac K 25mg) PO TID
{preparation and precaution - mephalan, post-IPP meeting following up}
patient family meeting and IPP meeting was held at 10:00 on 2021-08-24.
the schedule with regimen for PBSCT for the patient has been disclosed in the meeting.
melphalan dosing as a conditioning agent, 140mg/m2 or 200mg/m2 are more commonly seen. source:
the estimated total amount of melphalan used prior to the scheduled transplantation would be 8 vials.
preparation and administration precautions of mephalan:
damage of the oral mucosa together with profound myelo- and immunosuppression after transplantation may lead to local and systemic infections.
{sepsis and pancytopenia with underlying DLBCL}
[subjective]
[objective]
[assessment]
[suggestion]
{liver cancer with bone mets}
[initial presentation]
[definite diagnosis, disease extent, effect & side effect]
[treatment]
[assessment]
[suggestion]
{some preparation before tube feeding}
active medication is reviewed, all the oral drugs can be administered via NG tube.
acetin (acetylcysteine) and nexium (esomeprazole) should be dissolved in adequate drinking water prior to tube feeding.
{switch drug for tube feeding}
active medication has been reviewed, all the oral drugs can be administered via NG tube.
Harnalidge (tamsulosin) 0.4mg PO QDAC replaced by Urief (silodosin) 8mg PO QD is recommended.
{statin dose intensity and equivalency}
All the oral drugs in active medication have been reviewed and can be administered via NG tube.
Pravafen has not been found in active medication yet.
Pravafen should not be grinded or half-peeled. It contains fenofibrate 160mg and pravastatin 40mg, there is Lipanthyl Supra (fenofibrate 160mg) available in hospital, however pravastatin 40mg is out of stock for now.
Fluvastatin 80mg, lovastatin 80mg, simvastatin 20mg, pitavastatin 2mg, atorvastatin 10mg, rosuvastatin 5mg are alternatives for pravastatin 40mg. reference: http://www.mqic.org/pdf/UMHS_Statin_Dose_Intensity_and_Equivalency_Chart.pdf
{lung cancer with brain mets}
[initial presentation]
[definite diagnose, disease extent]
[treatment]
[assessment, suggestion]
{cecal cancer}
[initial presentation, definite diagnosis, disease extent]
[treatment]
[effect & side effect]
[ongoing problem]
[assessment]
{renal glucosuria?}
[objective]
[assessment]
[suggestion]
[initial presentation]
[definite diagnosis]
[disease extent]
[plan & treatment]
[effect & side effect]
[ongoing problem]
{flumarin side effect monitoring}
[objective]
[assessment]
[suggestion]
{cancer workup}
[initial presentation]
[objective]
[definite diagnosis & staging workup]
[treatment]
[ongoing problem]
[assessment]
{post IPP meeting following up}
the schedule and regimen for PBSCT for the patient was disclosed in the meeting held on 2021-07-28 10:30.
the estimated total amount of busulfan used in the time table is 15 vials.
staff dispensing regimen during weekend are arranged.
preparation and administration precautions:
{mesna administration rate}
{colon cancer}
[initial presentation]
[definite diagnosis and disease extent]
[treatment]
[effect & side effect]
[ongoing problem]
{coadministration of Decan and Juluca}
[objective]
[assessment]
[suggestion]
{vaccination for splenectomised patients}
[objective]
[assessment]
[suggestion]
{suspected MDS}
[objective]
[assessment]
[suggestion]
{Rectal Cancer with UTI}
[objective]
[assessment]
[suggestion]
{potential interactions among lorazepam, olanzapine, morphine and labetalol}
[objective]
[assessment]
[suggestion]
{potential interactions among alprazolam, olanzapine and zolpidem}
[objective]
[assessment]
[suggestion]
{potential interaction when coadministering alprazolam, metoclopramide, olanzapine}
[objective]
the following items are listed in active medication: - alpraline (alprazolam, 0.5mg/tab) 1 tab PO HS - promeran (metoclopramide, 3.84mg/tab) 1 tab PO TIDAC - zyprexa zydis (olanzapine, 5mg/tab) 1 tab PO HS
[assessment]
[suggestion]
{post-IPP meeting following up}
patient family meeting and IPP meeting was held at 10:00 on 2021-07-06
the schedule with regimen for PBSCT for the patient has been disclosed in the meeting.
the estimated total amount of melphalan used in the time table is 6 vials.
preparation and administration precautions of mephalan:
{form virless (acyclovir) to famvir (famciclovir)}
[objective]
[assessment]
[suggestion]
{reported thrombotic microangiopathy with acyclovir}
[objective]
[assessment]
[suggestion]
{acyclovir to treat herpes virus infection in HBV active carrier}
[objective]
[accessment]
[suggestion]
[initial presentation]
[definite diagnosis]
2021-05-06 CT - abd - loculated fluid accumulation at uterus up to
9.7*7.1cm in largest dimension is found. - uterine abscess is considered
first. 2021-05-11 patho - ovary (tumor) - taiwan society of pathology
was consulted to diagnose: malignant spindle cell and epithelioid cell
neoplasm. - IHC: SALL4/BRG1/INI1(+), glypican/SATB2/cyclinD1( focal+);
SS18-SSX/OCT4/CD30/ETV4/MDM2/S100/NUT/MyoD1(-).
- molecular pathology: SS18(-)(poor quality); chr12p/q FISH: failed. -
comment: - while the majority of it was composed of relatively uniform
spindle cells, gland-like components were also notable, in conjunction
with the strong TLE1 immunostaining, justifying your original
consideration of synovial sarcoma. - the degree of nuclear atypia would
be somewhat too high for synovial sarcoma, and TLE1 expression is not
specific. both SS18-SSX IHC and SS18 FISH performed to exclude this
possibility. - given the gland-like structures which reminded yolk sac
tumor, SALL4 (multifocally positive) and glypican (weakly positive,
mainly in the gland-like structures) staining were performed and
somewhat supported the speculation, albeit neither convincing nor
specific enough. - attempt to pursue some molecular evidence of
isochromosome 12p with chr12p, chr12q, and chr12 centromere FISH failed.
- other possibilities including myoepithelial carcinoma were not
supported by the current immunostaining results. - the case was reviewed
by one senior GYN pathologist, one GU pathologist, and another soft
tissue pathologist, and no conclusion could be drawn. - while a germ
cell tumor with a component of yolk sac tumor and sarcomatoid
transformation could not be excluded, the overall pathologic and
clinical features would be atypical. - perhaps a genomewide study aiming
at copy number variation/LOH might help in this regard. - note: some of
the original immunostaining showed CK weak+, TLE1+, SMA f+, GFAP-.
2021-07-13 patho - ovary (tumor) - diagnosis: pelvic tumor, debulking
surgery - compatible with recurrent malignant neoplasm. - the sections
show a picture of spindle and epithelioid cell tumor characterized by
spindle, ovoid or epithelioid tumor cells with congestion, hemorrhage,
extensive necrosis, active mitoses, arranged in solid, focal fascicular
or focal gland-like or rossette-like pattern, compatible with tumor
recurrence.
[treatment]
{potential abx absorption problem}
[objective]
[accessment]
[suggestion]
{tube feeding}
all the oral drugs in active medication have been reviewed, the following two items can be peeled half but should not be grinded: - Curam (amoxicillin 875 mg, clavulanic acid 125 mg, tab) - film coated - Pentop (pentoxifylline 400mg, tab)
and the following item can not be peeled half or grinded: - Nexium (esomeprazole 40mg, tab)
the alternatives to above items, respectively, could be: - Soonmelt (amoxicillin 500mg, clavulanic acid 100mg, vial), if half-peeled Curam still too big to be fed. - there is no other drug containing same active ingredient with Pentop in the inventory, so please peel it (not too fine) to fit the tube. - Takepron (lansoprazole 30mg, tab) should not be grinded but can be peeled half.
{tube feeding}
all the oral drugs in active medication can be administrated via NG tube except following items which should not be grinded:
{tube feeding}
the oral drug takepron (lansoprazole, 30mg/tab) in active medication should not be grinded, while it can be peeled in half.
there is also an iv version takepron (lansoprazole, 30mg/vial) can be the alternative.
{Tube Feeding}
all the oral drugs in current medication can be administrated via NG tube.
actein effervescent (acetylcysteine) should not be grinded, please dissolve the drug in adequate amount of drinking water prior to tube feeding.
{post IPP meeting following up}
the schedule with regimen for PBSCT for the patient is disclosed in the meeting.
the estimated total amount of busulfan used in the time table is 15 vials.
people for dispensing regimen during weekend are also arranged.
preparation and administration precautions:
{drug identification}
requesting drug identification for 6 items.
the 4 identified items has been shown as following while the other 2 items still remain unknown: - sinemet (carbidopa 25mg, levodopa 100mg) - urief (silodosin 4mg) - rivotril (clonazepam 2mg) - through (sennoside 12mg)
these drugs will be sent back to ward by the in-hospital porter.
{problem list}
the active problems listed in the TPR sheet are shown as following:
[objective]
[assessment]
[suggestion]
{problem list}
active problems listed in 2021-05-08 14:14 DutyNote containing 2 items: - urinary tract infection - right lower lung pneumonia
[subj/obj]
[assessment]
[suggestion]
{colon cancer}
[subj/obj]
[assessment]
[suggestion]
{substance dependence}
[subj/obj]
[assessment]
[suggestion]
{returning to society}
[subj/obj]
[assessment]
[suggestion]
{colon cancer}
[initial presentation]
[definite diagnosis]
[disease extent & staging]
[treatment & plan]
[effect & side effect]
[ongoing problem]
{colon cancer}
[objective]
[assessment]
[suggest/plan]
{intrahepatic cholangiocarcinoma}
[initial presentaion]
[definite diagnosis]
[disease extent]
[treatment]
[effect and side effect]
[ongoing problem]
HCV, Cirrhosis, Child A - 2021-03-30 - HBsAg Nonreactive - Anti-HBc Reactive - Anti-HCV Reactive
hypertention, portal hypertension varicose vein GERD type 2 DM
2018-10 diarrhea on and off
2020-11-12 patho - colon biopsy
2020-11-12 CT, ABD: cT3N2aMia, stage IVA Re-evaluation on 12/14/2020 slightly decreased in tumor size.
2020 late Nov ~ 2021 early Jan CCRT, FU/LV 5040 cGy/28Fx in hope of receiving sphincter preserving surgery (Last RT on 1/5).
2021 Feb there after chemo FOLFOX
2021-02-18 CT, ABD: much regression of rectal cancer.
2021-03-10 Op Method: Abdominoperineal resection (APR)
Finding: 1. Tumor in rectum, cT3N2aM1a (enlarged nodes in left external
iliac chain) 2. End S colostomy is done over LLQ
3. One JV drain at pelvic area
rectal cancer, cT3N2aM1a s/p CCRT, was admitted for scheduled laparoscopic APR with permanent colostomy. - 2021-03-18 patho - abdomino-perineum resection - ypT3N1aMia stage IVA
2021-05-13 Self-Monitoring of Blood Glucose,SMBG QDAC
PatMRNo, PatID, PatName, PatBDate, PatGender
Brosym 4g Q12H
assumed 50kg body weight with Cockcroft-Gault formula, the estimated CrCl is 25mL/min, daily maximal dose is 4g (2g Q12H) according to package insert.
cefoperazone sulbactam
daily maximal 4g (2g Q12H)
Nexium (esomeprazole) should not be grinded, shifting to Takepron (lansoprazole) is recommended.
Actein should be dissolved in adequate drinking water prior to tube feeding.
thanks and regards,
all the oral drugs in active medication can be administrated via NG tube except Doxaben XL (doxazosin) which is release-controlled.
Urief (silodosin) is recommended as an alternative to switch Doxaben.
thanks and regards,
omeprazole lansoprazole pantoprazole rabeprazole
[objective]
{rectal cancer}
[initial presentation]
[definite diagnosis]
[disease extent & staging]
[treatment]
[effect & side effect]
[ongoing problem]
Decreased chemotherapy dose to 67 % for grade 3 diarrhea with blody weight loss. Decreased chemotherapy dose to 75 % for grade 2 diarrhea with blody weight loss.
{colon cancer}
701263241__999999__MNote
{colon cancer}
[objective]
2019-05-21 colonoscopy: one ulceative mass lesion with lumen stenosis over 15 cm from anal verge, patho - adenocarcinoma.
2019-06-12 laparoscopic anterior resection and partial cystectomy, findings:
2019-09-10 CT: recurrence over left pelvis, and omentum of LLQ.
stayed in USA for months, lost following up in Taiwan health care provider.
2021-01-04 CT abdomen: colon cancer s/p operation with peritoneal carcinomatosis with massive ascites, T0N0M1c, Stage IVC.
2021-04-06 CT abdomen, pelvis:
2021-04-16 ascites tapping: 3075cc clear yellowish ascites was drained.
2021-04-20 cyto, ascites: smears show clusters of pleomorphic tumor cells. the morphology is consistent with metastatic adenocarcinoma.
CEA
CA199
CA125
regimen
[assessment]
701265877
{Colon cancer}
[subj/obj]
(transverse) colon cancer with liver metastases, cT4aN1aM1c, stage IV s/p LPS right extended and hemicolectomy on 2020-03-26 and seedings over omentum found.
chemo (palliative) from 2020-04-27 with FOLFOXIRI (ox: self-paid; iri: insurance covered) with bevacizumab.
chest echography on 2021-02-23 showed right thorax pleural effusion s/p drainage of 600 cc.
CXR on 2021-03-09 showed right thorax small pleural effusion.
CEA:
CA199:
for 3 consecutive weeks then 1 week off as a cycle
Oral target therapy with Cobimetinib 20mg 1# po QD (self-carried) (for 3 consecutive weeks then 1 week off as a cycle) from 2021/02/24~2021/0314. Oral target therapy with Dabrafenib 75mg 2# po Q12H (self-carried) (for 3 consecutive weeks then 1 week off as a cycle) from 2021/02/24. Chemotherapy with biweekly Erbitux(500mg)/Campto(100mg) (C1D1) on 2021/02/24, (C1D15) on 2021/03/10, (C2D1) on 2021/03/24, (C2D15) on 2021/04/07. Oral target therapy with Mekinisc 2mg 1# po QDAC(self-paid) from 2021/03/15 (for 3 consecutive weeks then 1 week off as a cycle). Therefore, the treatment would be cetuximab plus irinotecan(C1D15) and dabrafenib and MEK inhiitor, under the recognition of T-colon cancer with metastases to liver, peritoneum and pleura, and with B-Raf mutation. This time, she was admitted for Chemotherapy with biweekly Erbitux(500mg)/Campto(100mg) (C3D1) on 2021/4/22.
Oral target therapy with Dabrafenib(Tafinlar) 75mg 1# po BID(self-carried) from 2021/02/24 Oral target therapy with Mekinisc 2mg 1# po QDAC(self pay) from 2021/03/15. Chemotherapy with biweekly Erbitux(500mg)/Campto(100mg) (C3D1) from on 2021/04/23
{colon cancer}
[objective]
[assessment]
[suggestion]
{}
[initial presentation]
[definite diagnosis]
[disease extent]
[Summary]
This 67-year-old woman has the history of 1: Solitary pulmonary nodule, r/o malignancy 2: Type 2 DM Parapneumonic effusion, right This time, she has suffered from dyspnea for weeks. Since the symptom exacerbation recent days. She was then brought to our ER for further help. At ER, rapid screeing of COVID19 revealed negative finding. CXR showed bilateral consolidation and pleural effusions, cardiomegaly. Lab exam revealed elevated CRP. Under the impression of suspect COVID19 pnuemonia, right lung mass and bilateral pleural effusion, the patient was admitted for further care on 20210629.
Bilateral pneumonia Bilateral pleural effusion r/o COVID -19 infection
=> Abx with Brosym => Oxygen supplement => Oral radi-K => Diuretic for bilateral plerual effusion => Transfer to CM ward if PCR negative
==============================
This 67-year-old woman has the history of 1: Solitary pulmonary nodule, r/o malignancy 2: Type 2 DM 3: Parapneumonic effusion, right.Under the impression of suspect COVID19 pnuemonia, right lung mass and bilateral pleural effusion, the patient was admitted for further care on 20210629.After admission. antiboitc with Brosym for pneumonia and fiuretic for bilateral plerual effusion were given. RT-PCR of COVID-19 revealed negative finding. The patient might transfer to chest ward for further management on 2021/06/29.
After CM ward, she has been orthopnea and dyspnea was noted, well explained present condition and treatment plan to the patient and her husband, emergency arrange cardiac echo and chest echo for right lung mass, pericardial effusion and bilateral pleural effusion for evaluation. Cardiac echo and chest echo was done and smoothly on 06/30, cardiac echo showed moderate amount pericardial effusion, No RV compression sign, No tamponade, No pericardial constriction at present, recommended to consult with cardiac surgery for P.P. window. Chest echo report showed Left side massive amount of pleural effusion, s/p thoracentesis, yield 1000cc, serosanguos fluid. Right side minimal amount of pleural effusion. She was transferre to SICU for intensive care on 6/30. We consult CVS for moderate amount pericardial effusion and P.P window surgery(Pericardiac effusion:1350cc) on 7/01. All operation procedure smoothly and return SICU for postoperation care. Weaning ventilaotr with etubated on 7/01. Under hemodynamic stable and she will be transfer to ward for care.
After transfered to Chest ward on 7/3, Tumor marker showed elevated CA-125, CA199, 7/6 CT guide biopsy was done and patho showed adenocarcinoma with TFF-1(-), abdomen CT showed ascites and multiple soft tissue nodules in the omentum, pending cytology, and lobulated pleura thickening at right anterior basl CP angle that may be tumor seeding or primary pleura tumor. brain MRI showed No brain nodule or metastasis, EGD+colonscopy was done on 7/12 showed gastric adenocarcinoma, bone scan was done on 7/13, whole body PET was done on 7/15 revealed prominent glucose hypermetabolic lesion in the right lateral aspect of the pharyngeal wall, we will consult ENT for assessment, she was transfered to hema ward on 7/16 for further assessment and management.
{metastatic renal cell carcinoma}
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The patient suffered from SOB, air hunger, cold sweat, and the cold of four limbs, the 12 lead EKG: sinus tachycardia, the heart rate from 139bpm to 58bpm, the blood oxygen drop, changed the oxygen support with NRM O2 fll, the SpO2 97%, then we can’t measure blood pressure, and the patient consciousness become drowsy and the blood oxygen drop again, under the NRM O2 full. The VS Xia talks about the patient’s condition to the family, so gave the endo inserting, on levophed and Dopamin high dose will be transferred to MICU.